SH Infectious Disease (including COVID-19) Student Registration Form COURSE DATAInfectious Diseases (Including COVID-19) TrainingThis training is funded by a Susan Harwood Training Grant from the U.S. Department of Labor (Grant# SH-36981-HA10).Course Title*Choose Course TitleInfectious Disease Training for Longterm Care Workers – 1 HourInfectious Disease Training for Longterm Care Workers – Full DayInfectious Disease Training for Funeral Home Workers – 1 HourInfectious Disease Training for Funeral Home Workers – Full DayCourse Date* Course Location (if Virtual, enter "Online" below)* Instructor(s) Name(s)*Vicki Hanrahan AinslieSean CastilloBob HendryJenny HoulroydToni MilesBrandon PhilpotSelect all instructors who took part in your training course.PERSONAL DATA & GEORGIA TECH DATALegal Last Name* Legal First Name* MI Gender* Male Female Prefer not to respond Job Title* Job Responsibilities*Email* Phone*Street Address* City* State* Zip* Address Type* Home Work Preferred First Name* EMPLOYER DATAName of Employer State Zip STUDENT GROUPS (mark “X” on appropriate line) Federal OSHA Personnel State OSHA Personnel Private Sector Personnel Other Federal Agency Personnel Other State or Municipal Personnel Foreign Student Signature Reset signature Signature locked. Reset to sign again Δ
