JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
MEIR Registration
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Full Name (Last, First MI)
*
Your answer
Rank/Rate or Title
*
Your answer
DoD ID
*
Your answer
Command/Organization Name (No Acronyms)
*
Your answer
Service
*
Air Force
Air National Guard
Army
Army National Guard
Coast Guard
Civilian
Contractor
Marine Corps
Navy
Public Health Service
Space Force
Other:
Work Email Address
*
Your answer
Phone Number (For course updates in the case of emergencies or inclement weather.)
*
Your answer
Job Description (e.g. physician, medical planner, first responder, CBRNE specialist, health physicist, etc.)
*
Your answer
Rate your familiarity with radiation protection and health physics.
*
1 Not familiar at all
2 My duties include radiation protection and health physics, but they are not my primary duties.
3 My daily duties involve radiation protection and health physics.
Rate your familiarity with medical response and patient management.
*
1 Not familiar at all
2 My duties include medical response and patient management, but they are not my primary duties.
3 My daily duties involve medical response and patient management.
Supervisor's Name
*
Your answer
Supervisor's Email
*
Your answer
Supervisor's Phone Number
*
Your answer
*
If I am unable to attend the course, I will send an email to
aure.stewart@usuhs.edu
or
nina.barr@usuhs.edu
to confirm disenrollment. When a student fails to report without notice a seat goes unused and results in a loss of personnel accountability, which could result in adverse personnel action. If I fail to report without prior notice, I recognize that my supervisor will be informed.
Required
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Usuhs.edu.
Report Abuse
Forms
