Injury and Illness Prevention Program (IIPP) Training

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:fvasquez@irle.ucla.edu
Website:www.losh.ucla.edu
Youwillreceivearegistrationconfirmationnotebyemail.
UCLA Labor Occupational Safety & Health Program