InjuryandIllnessPreventionProgram(IIPP)Training REGISTRATIONFORM Dateofworkshopyouareregisteringfor: Locationofworkshopyouareregisteringfor: REGISTRANTINFORMATION FirstandLastName: EmailAddress(required): PreferredContactPhoneNumber: NameofBusiness: JobTitle/Occupation: Owner Manager Other: BusinessStreetAddress: City: State: ZipCode: Whatbestdescribesyourtypeofbusiness? (e.g.restaurant,buildingmaintenance,manufacturing,etc.) Areyouthedesignatedpersonresponsibleforworkerhealthandsafetyatyourbusiness? IfNO,istheresuchaperson? Yes Yes No No Approximatelyhowmanypeopleworkinyourbusiness? 1‐5 11‐20 51‐75 151‐250 6‐10 21‐50 76‐150 250+ Whatlanguage(s)doyouremployeesspeak? English Spanish Chinese(Mandarin/Cantonese) Other: Pleaselistanyorganizationsorassociationsyourbusinessisaffiliatedwith. TRAININGINFORMATION Whatmotivatedyoutoattendthistraining?Checkallthatapply. Highworkers’compensationcosts Recommendedbyworkers’compensationinsurer Injuriesatmyworkplace Concernedabouthealthandsafety CitedbyCal/OSHAfornothavinganIIPP Openinganewbusiness Other: Haveyouattendedanyotherworkplacehealthandsafetytrainingsessionsinthepastfiveyears? No,0trainings Yes,1‐2trainings Yes,3+trainings Notsure Howdidyouhearaboutthistraining? Invitationletter Business/tradeassociation Insurancecarrier Other: Whatareyoumosthopingtogetoutofthecourse? PleasesubmitthisIIPPregistrationformbyemailorfaxatleastoneweekbeforethetrainingto: FlorVasquez UCLALaborOccupationalSafety&Health(LOSH)Program Fax:310‐794‐6403 Email:[email protected] Website:www.losh.ucla.edu Youwillreceivearegistrationconfirmationnotebyemail. UCLA Labor Occupational Safety & Health Program