Worker Occupational Safety and Health (WOSH) Specialist Training

Worker Occupational Safety and Health (WOSH) Specialist Training

REGISTRATION FORM

Register online at www.lohp/woshtep.

Date of workshop you are registering for: ______

Location of workshop you are registering for: ______

How did you hear about this training?
Employer Teacher Website Presentation
Co-workers Insurer Media Previous Class
Union Newsletter Mailing/Flyer Other:

REGISTRANT INFORMATION

First and Last Name (as you would like it to appear on your Certificate of Completion):

______

Email Address: ______Preferred Contact Phone Number: ______

Preferred Mailing Address
Street: ______City: ______State: _____ Zip Code: ______
To which racial or ethnic group(s) do you most identify? Check all that apply.
Hispanic or Latino Native Hawaiian or Pacific Islander Alaska Native
White or Caucasian American Indian Black or African-American
Asian Other:

What language(s) do you speak at home?
English Vietnamese Russian Filipino/Tagalog
Spanish Chinese (Mandarin/Cantonese) Korean Other:

What is your gender? Male Female Other:

Age Range:
15 -19 35-54 75 and over
20 -34 55-74

EMPLOYMENT INFORMATION

Employer: ______Job Title/Occupation: ______Department: ______

Work Street Address: ______City: ______State: _____ Zip Code: ______

What is the main language(s) spoken at your workplace?
English Vietnamese Russian Filipino/Tagalog
Spanish Chinese (Mandarin/Cantonese) Korean Other:
Have you attended any workplace health and safety training sessions in the past 5 years ?

No, 0 trainings Yes, 1-2 trainings Yes 3+ trainings Not sure

If yes, on what topic? ______

Do you currently have a health and safety leadership role at your workplace?
Shop steward Member of health and safety committee Safety coordinator Other:

Is there a health and safety committee at your workplace? Yes No I don't know

Do you think your employer (or other sponsoring group) will support your efforts to improve workplace health and safety?

Yes, very likely Maybe No, not very likely Not sure
INDUSTRY INFORMATION

Do you work for a Private company or Public agency (government, university, etc.)?
Private
Public – State
Public – County
Public – City

Please indicate the primary business activities of your company or organization:

Private Sector
Industry Group: / Industry Activity:
Agriculture / Greenhouse and Nursery Production
Animal Production and Aquaculture
Other:
Construction / Framing Contractors
Other:
Manufacturing / Animal Slaughtering and Processing
Soft Drink and Ice Manufacturing
Textile Product Mills
Leather and Allied Product Manufacturing
Sawmills and Wood Preservation
Other Wood Product Manufacturing
Glass and Glass Product Manufacturing
Ferrous Metal Foundries
Motor Vehicle Body and Trailer
Furniture Related Product Manufacturing
Other:
Wholesale Trade / Specify Activity:
Retail Trade / Motor Vehicle Dealers
Other:
Transportation and Warehousing / Air Transportation
Couriers and Messengers
Warehousing and Storage
Other:
Utilities / Specify Activity:
Information / Specify Activity:
Finance and Insurance / Specify Activity:
Real Estate and Rental and Leasing / Specify Activity:
Professional, Scientific, and Technical Services / Specify Activity:
Management of Companies and Enterprises / Specify Activity:
Administrative and Support and Waste Management and Remediation Services / Waste Management and Remediation Service
Waste Treatment and Disposal
Other:
Educational Services / Specify Activity:
Healthcare and Social Assistance / Specify Activity
Arts, Entertainment, and Recreation / Specify Activity:
Accommodation and Food Services / Accommodation
Other:
Other Services, except Public Administration (such as: repair and maintenance, personal and laundry services, religious, grantmaking, civic, professional, and similar organizations,etc). / Specify:
Other: / Other:
Public Sector
Industry Group / Industry Activity
Construction / Heavy and Civil Engineering Construction
Other:
Transportation and Warehousing / Transit and Ground Passenger Transportation
Other:
Utilities / Specify Activity
Educational Services / Specify Activity
Healthcare and Social Assistance / Hospitals
Nursing and Residential Care Facilities
Other:
Arts, Entertainment, and Recreation / Amusement, Gambling, and Recreation Industries
Other:
Public Administration / Justice, public order, and safety activities. Please specify if:
Fire Protection
Police Protection
Correctional Institutions
Other:
Other: / Other:

UNION INFORMATION

Are there any unions representing workers in your workplace? Yes No I don’t know

Are you a member of a union? Yes No If YES, what union? ______

Do you have a leadership role in your union? If yes, what is your title or role?

Please submit this WOSH registration form by email or fax prior to the training to:

Kelly Chan

Labor Occupational Health Program, UC Berkeley

Fax: 510-643-5698

Email:

Website: www.lohp.org/woshtep

You will receive a registration confirmation note by email.

UC Berkeley Labor Occupational Health Program