_____________
ID Number*

_______________________________________
Name

____ / ____ / ____
Expiration Date

*ID number – new trainers do not have - only applies to trainers who have received student cards

 Check if this is a new address

Company / Dept. __________________________________________________________

Address __________________________________________________________

__________________________________________________________

City /State /Zip __________________________________________________________

Phone No: (_____) - _____ - _______ ext. ______

Best time(s) to call:________________

1. Disaster Site Worker Outreach Training Program Report – including complete Training Certifications and Information section.
2. Student names
3. A copy of your course certificate or trainer card if you do not have an ID#

• Student evaluation forms
• Student sign-in sheets from each day of the course

_____ (Check) I certify that I taught all the required topics and met the Lesson Objectives of the Disaster Site Worker Course #7600.
_____ (Check) I certify that I conducted the training for a minimum of 16 hours.
_____ (Check) I certify that I have maintained supporting documentation on the respirator performance checklists and scores.

The range of scores that I recorded for the Operations Performance Score in the respiratory protection performance test: FROM ________ TO ________

Trainer Signature ________________________________________________