LOSH 24-hour HAZWOPER Training Registration
Please begin your enrollment by completing and submitting the form below. After submission, you will be contacted via email regarding next steps.

Note: To be added to the roster, students must enroll at least 3 business days before the course begins.

Training registration will close when class enrollment is full (Max. 15 trainees).

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Date of Birth
mm/dd
Training Agency
Location
Name of Course *
Date (TBA)* *
First Name *
Last Name *
Home Address *
City *
State *
ZIP *
Phone # *
Home Email Address *
Contact for Payment (if different, please provide name, email & phone number)
Payment Method *
Due to COVID-19, we highly encourage CARD payments. Check payments are still accepted, however your certification may be delayed due to late-check arrivals.
Are you currently employed? *
SECTION A - WORKPLACE INFORMATION
Note: if you are currently employed, please complete SECTION A. If not, skip to SECTION C - Information About You
Name of Employer
Employer Address
City (Employer)
State (Employer)
ZIP (Employer)
Work Phone #
Work Email Address
What is your job title?
Please do not use abbreviations.
What type of employer do you work for?
Clear selection
Do you belong to a union?
Clear selection
If you belong to a union, please provide Union and Local
What best describes the type of industry where you work? *
Please check ONE only. If working as a consultant or inspector, choose teh item that best describes your clients' or inspection industry.
SECTION B - WORKSITE HAZMAT ACTIVITIES
What best describes the type of hazardous waste/HAZMAT operations at your worksite? *
If working as a consultant or inspector, choose the item that best describes your clients' or inspection sites.
What will be your routine job duties in the next 12 months? *
SECTION C - INFORMATION ABOUT YOU
Our funders (NIEHS) have asked us to gather more information about the people we train so they can learn more about hazardous workers. We would appreciate your answers to the following questions:
Gender
Clear selection
What language do you speak at home?
Clear selection
What is your ethnic/racial background?
If multiple, please indicate the one you would prefer to report:
Clear selection
What is your age?
What is the highest level of education you have completed?
How did you hear about our training? *
We would like to hear from you! (Optional)
What is one substance, chemical, element of concern, or hazard you encounter in your workplace or are interested in that you would like UCLA LOSH to address during training sessions? Please submit your answer in the text box below.

All submitted responses will help us provide a more central/realistic approach to our training's examples, methodologies, and concepts to meet your training needs.
ex. Asbestos exposure from mining operations
DISCLAIMER
Notice: By submitting this registration form you are providing consent to receive follow-up communication emails from UCLA LOSH. You will be able to opt out of these communications at any time.
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