Form Approved/OMB No. 0920-0217
Expiration Date: 5/31/2016
NCHS VITAL STATISTICS TRAINING APPLICATION
1. NAME OF APPLICANT: (Please type or print: Last, First, Middle)
_________________________________________ First Name for Badge ______________
2. COURSE REQUESTED: VITAL STATISTICS RECORDS AND THEIR ADMINISTRATION
Date: ________________________________________________________
Location: _____________________________________________________
3. SPONSOR OR EMPLOYER:
Organization: (Please specify)
__________________________________________________________________________
Address: (Street and/or POB, City, State, Zip Code)
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Office Phone: (Area code and number) _______________________________
E-mail:_____________________ Fax: ______________________________
4. OCCUPATION: _________________________________________________________________
5. BRIEF DESCRIPTION OF YOUR PRESENT JOB:
___________________________________________________________________________
___________________________________________________________________________
6. NUMBER OF YEARS IN CURRENT FIELD OF WORK: _________________________________
7. STATE OR LOCAL PERSONNEL: S: ____ L: ____
8. EDUCATION: Attended college? No: ____ Yes: ____
If yes, specify highest degree or number of year’s attended____________________________
Major subject(s) of study______________________________________________________
9. ATTENDANCE: Attended this course before? No: ______ Yes: ______ what year? _______
Section 304 (b) of the PHS Act (42 USC 242b) authorizes the DHHS Secretary to provide technical assistance in matters relating to health statistical activities. The principal purpose of the information requested in this form is to select students for training. This information may be disclosed to instructors. Provision of the requested information is voluntary; however, failure to supply all information may delay or prevent action on your application.
Public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of the collection of this information, including suggestions for reducing this burden, to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0217).
SIGNATURE OF APPLICANT: ________________________________________
SIGNATURE OF SUPERVISOR: ________________________________________
Please return completed and signed form via email as soon as possible to:
LaDonna Crayton E-mail: lcrayton@cdc.gov
Registration Methods Specialist Telephone: 301-458-4398
NCHS-DVS-OD
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Disease Control and Prevention
National Center for Health Statistics
File Type | application/msword |
Author | jaw4 |
Last Modified By | VCB Comments |
File Modified | 2016-04-05 |
File Created | 2016-04-05 |