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CDC & ATSDR


New Participant Registration
Participant Profile
  Action: Approved
OMB No.: 0920-0017
Exp. Date: 5/31/2016
* First Name  
* Last Name  
Middle Initial  
* Address  
 
* City  
* State  
*+ Zip Code:  
* Country:  
  Daytime Telephone:  
 
* Are you a CDC/ATSDR employee? Yes     No
* Are you in the military? Yes    No    If so what branch?
 
* Place of employment
 
* E-Mail:  
* Confirm E-Mail:  
  Note: You must enter the correct email address to register online.
 
Click here if you wish to be notified via email of upcoming events or other information.
 
* = Required Items   + = For U.S. Only
 
Public Burden Statement:

The information requested on this form is collected under the authority of 42 U.S.C., Section 243 (CDC) and the Comprehensive Environmental Response, Compensation, and Liability Act (CERCLA) (42 U.S.C. 9604 (i)) and its 1986 Amendments, The Superfund Amendments and Reauthorization Act (SARA) (ATSDR). The requested information is used only to process your training registration and will be disclosed only upon your written request. Continuing education credit can only be provided when all requested information is submitted.

Public reporting burden of this collection of information is estimated to average 5 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 Reports Clearance Officer; 1600 Clifton Road NE, MS D-24, Atlanta, Georgia 30333; ATTN: PRA (0920-0017)
 
 
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Centers for Disease Control and Prevention, 1600 Clifton Rd, Atlanta, GA 30333, U.S.A
Tel: (404) 639-3311 / Public Inquiries: (404) 639-3534 / (800) 311-3435
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