SASH Registration Form 11-17-21
*Promoting Safe and Healthy Workplaces for California's School Employees*
This virtual training is FREE for School District and County Office of Education employees.

Please complete this form to register for a SASH workshop.
Questions? Contact Rosa Maria Martinez at rmm@berkeley.edu
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Training Date you would like to attend: *
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Registrant Information
First Name: *
Please enter your name as you'd like it to appear on your certificate of completion.
Last Name: *
Preferred email address: *
Is this your work email? *
Direct phone number:  (xxx-xx-xxxx) *
Is this your work phone? *
Preferred Mailing Address Street *
Preferred Mailing Address City *
State *
Preferred Mailing Address ZIP *
Is this your work address? *
Employer: *
Is your employer a: *
What county do you work in? *
If you work for a school or school district, what department do you work in?
Clear selection
Your Job Title/ Position *
What language(s) do you speak at home? (Check all that apply) *
Required
Have you attended any prior health and safety training lasting more than 2 hours: *
Required
Are you a member of a union? *
If Yes, which union?
If Yes, do you have a leadership role?
Is there a health and safety committee that includes a focus on employee health and safety? *
Are you responsible for carrying out health and safety activities in your district?
Clear selection
Are you responsible for writing your district's Injury and Illness Prevention Plan? *
Are you responsible for writing your district's COVID-19 Protection plan? *
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