eForm

US Army Center for Health Promotion and Preventive Medicine

Training & Conferences

Registration/Application Request

On Site Training Request

Your Name:		Your E-Mail Address:		Alternate E-Mail Address:

Comm Phone Number:		DSN Phone Number:		Commercial Phone Number:

Office Mailing Address

Please check the course you're requesting:

Basic Waste Management Workshop			Transport of Biomedical Materials

Transport of Regulated Medical Waste			Pharmaceutical Waste Management

First Quarter			Second Quarter			Third Quarter			Fourth Quarter

Number of Personnel to be Trained:		Primary Dates for Training:		Alternate Training Dates:

AOC/MOS/specialty&#47educational background of personnel to be trained:

Please explain why your organization needs this training:

Has your organization received any notices of violation, citations or deficiencies during any environmental inspections &#40federal, state or DoD&#41&#63</B></td> </tr><tr> <td></td> </tr> </table></td> </tr><tr> <td><table cellspacing="2" cellpadding="2" border="0"> <tr> <td>   Yes &#40If &#34Yes&#34&#44 please explain&#46&#41</td><td><input id="Violations yes@V@Yes &#40If &#34Yes&#34&#44 please explain&#46&#41##37" type="checkbox" name="Violations yes@V@Yes &#40If &#34Yes&#34&#44 please explain&#46&#41##37" /></td><td>   No</td><td><input id="Violations No@V@No##38" type="checkbox" name="Violations No@V@No##38" /></td> </tr><tr> </tr> </table></td> </tr><tr> <td><table cellspacing="2" cellpadding="2" border="0"> <tr> <td><b></b><br></td> </tr><tr> <td><textarea name="Yes Explanation" rows="4" id="Yes Explanation" COLS="60"></textarea></td> </tr> </table></td> </tr><tr> <td><table cellspacing="2" cellpadding="2" border="0"> <tr> <td><B>Is your organization able to provide funding for this onsite training&#63</B></td> </tr><tr> <td></td> </tr> </table></td> </tr><tr> <td><table cellspacing="2" cellpadding="2" border="0"> <tr> <td>   Yes</td><td><input id="Funds Yes@V@Yes##41" type="checkbox" name="Funds Yes@V@Yes##41" /></td><td>   No &#40If&#34No&#34&#44 please explain&#46&#41</td><td><input id="Funds No@V@No &#40If&#34No&#34&#44 please explain&#46&#41##42" type="checkbox" name="Funds No@V@No &#40If&#34No&#34&#44 please explain&#46&#41##42" /></td> </tr><tr> </tr> </table></td> </tr><tr> <td><table cellspacing="2" cellpadding="2" border="0"> <tr> <td><b></b><br></td> </tr><tr> <td><textarea name="Funds No Explaination" rows="4" id="Funds No Explaination" COLS="60"></textarea></td> </tr> </table></td> </tr><tr> <td><table cellspacing="2" cellpadding="2" border="0"> <tr> <td><b>What is the impact upon your organization if you do not receive this training&#63</b><br></td> </tr><tr> <td><textarea name="Impact with No Training" rows="4" id="Impact with No Training" COLS="60"></textarea></td> </tr> </table></td> </tr><tr> <td><table cellspacing="2" cellpadding="2" border="0"> <tr> <td><b>What are your training expectations&#63</b><br></td> </tr><tr> <td><textarea name="Expectations" rows="4" id="Expectations" COLS="60"></textarea></td> </tr> </table></td> </tr><tr> <td><table cellspacing="2" cellpadding="2" border="0"> <tr> <td><b>List any previous training your organization has received in this area&#44 &#40please state who provided the training&#41&#46</b><br></td> </tr><tr> <td><textarea name="Previous Organizational Tng" rows="4" id="Previous Organizational Tng" COLS="60"></textarea></td> </tr> </table></td> </tr><tr> <td><table cellspacing="2" cellpadding="2" border="0"> <tr> <td><b>Questions&#47Concerns&#58</b><br></td> </tr><tr> <td><textarea name="Questions or Concerns" rows="4" id="Questions or Concerns" COLS="60"></textarea></td> </tr> </table></td> </tr> </table><br> <input type="submit" name="Button1" value="Submit" id="Button1" /></form> </body> </HTML>