Needs Assessment Form

Please enter your e-mail address:

(This is the only required field in the form)

If you would like us to send further information on our course offerings, please provide your contact information here.

Name

Company/Organization

Title

Postal Address

Phone Number

Fax Number

Your profession? (pick one)
Occupational Medicine Industrial Hygiene Occupational Health Nursing Occupational Safety Physical/Occupt'nl Therapy Engineering Management or Supervision Labor Representative Other (add comments below)

Your employer category? (pick one)
Private Industry Independent Consultant Organized Labor Academic Institution Insurance Federal Government State Government Local Government Other (add comments below)

Advertisements or announcements in publications
Receiving direct mail program flyers
Local professional society announcement
Word-of-mouth from colleagues
Publicity via email lists, or the World Wide Web
Other (please describe in the comments box below)

Would you consider registering for an NC ERC continuing education activity in one of the following formats (Check as many as apply.):

Website
CD_ROM
satellite television

(Please add any comments in the box below)

Comments and Questions

Please consider the following topic areas and check those in which your need for continuing education is high.

Professional Review Courses

Management and Legal Issues

Information Tools and Communications Resources

General Occupational Practice

Specific Workplace Hazards and Concerns

Comments on needs for specific continuing education programs