IIPP Registration Form

Complete this form to register for an IIPP workshop.
Questions? Contact Robin Dewey at rdewey@berkeley.edu
For more information, visit www.lohp.org/IIPP.
WORKSHOP INFORMATION
Date of the workshop you are registering for: *
MM
/
DD
/
YYYY
Location of the workshop you are registering for: *
(e.g. Sacramento, Modesto)
Your answer
REGISTRANT INFORMATION
First & Last Name: *
Your answer
Email Address: *
Your answer
Preferred Contact Phone Number: *
Your answer
Name of Business: *
Your answer
Job Title/Occupation: *
Business Street Address: *
Your answer
Business City, State, and Zip Code: *
Your answer
Private or Public *
INDUSTRY (primary business activities of company or organization): *
If other industry not listed above, please specify. *
If not applicable, enter N/A.
Your answer
Please select the INDUSTRY ACTIVITY that best describes your company or organization. *
If other industry activity not listed above, please specify. *
If not applicable, enter N/A.
Your answer
Are you the designated person responsible for worker health and safety at your business? *
If NO, is there such a person?
Approximately how many people work in your business? *
What language(s) do your employees speak? *
Check all that apply.
Required
Please list any organizations or associations your business is affiliated with.
Your answer
TRAINING INFORMATION
What motivated you to attend this training? *
Check all that apply.
Required
Have you attended any other workplace health and safety training sessions in the past 5 years? *
How did you hear about this training? *
Check all that apply.
Required
What are you most hoping to get out of this course?
Please briefly explain.
Your answer
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