Annual report

ATTACHMENT D

NIOSH Spirometry Training Program Annual Report

Form Approved

OMB NO. 0920-0138

Expiration Date: 11/30/20xx

NIOSH Spirometry Training Program Annual Report

Please submit this form to STPReports@cdc.gov.

RE: NIOSH-APPROVED COURSE NO. __________

1. Conducting Courses ☐ Yes ☐ No

2. Initial Course

Course Location (state/country) Course Dates No. Students Trained

3. Refresher Course

Course Location (state/country) Course Dates No. Students Trained

4. Are any of the listed faculty members no longer teaching in your course? Faculty (lecturers and practicum instructors) must be approved by NIOSH. Please send NIOSH a request for approval and a current CV for prospective faculty members.

Faculty Member Name No Longer Teaching

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Public reporting burden of this collection of information is estimated to average 28 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 this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0138).