US Army Center for Health Promotion and Preventive Medicine
Training & Conferences

Registration/Application Request

Defense Occupational and Environmental Health Readiness System-Hearing Conservation (DOHRS-HC)
                                                                                Please check your preferred date.
                                                
   Certification, 17 - 20 May 2005                                                                   Recertification, 18 - 19 May 2005
   Certification, 23 - 26 May 2005                                                                   Recertification, 24 - 25 May 2005
Privacy Act Statement
 Title 5 US Code, Section 301; Executive Order 9397 authorizes the use of your Social Security Number as an identification number. The purpose of this information is for recordkeeping only. Having read the preceding Privacy Act Statement submission of this electronic form indicates applicants consent.
Fields marked with a red * are required. Use the TAB Key to navigate from field to field.
*Name:               
*Job Series&#47AOC&#47AFSC:   
*Grade/Rank:      
*Social Security Number:   
*Job Title:          
Component: Army, Navy, Civilian DAC, (Non-Gvt)/ Contractor, etc.:   
Gender:   Male   Female
Complete, Official, Office Mailing Address:
DSN Phone Number:         
Commercial Phone Number:   
Commercial Fax Number:   
*Primary E-mail Address:                    
Additional E-Mail Address:   
Have you been previously certified?   Yes   NoIf yes:
Certification Number:   
Where were you certified?   
Have you ever been trained on the DOHRS-HC?   Yes   No
Have you used the DOHRS-HC?   Yes   No
If yes, how long?   
In what capacity? (ie, backup, download, data entry, hearing testing, etc)
Provide your Hearing Conservation Officer's name and phone number:
It is necessary for the applicant to have verbal supervisory approval before submission of this form.
Supervisor's Name      
Supervisor's Title     
Supervisor's E-Mail    
Supervisor's Phone     
If you have questions on course content, submit them by E-mail to the workshop coordinator Dr. Don Ciliax