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Look for upcoming program announcements on
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University of California, Los Angeles
Public Health/Environmental Health Sciences
405 Hilgard Ave
BOX 951772
Los Angeles, CA 90095-1772
TuesdayͲThursday,June18Ͳ20,2013
Occupational Health and Safety Principles
and
Nursing Certification Review
Location: UCLA
Southern California
Education and Research Center
Continuing Education/Outreach
The Southern California Education and
Research Center is a NIOSH ERC
Southern California
Education and Research Center
Occupational Health and Safety Principles and
Nursing Certification Review — June 2013
Registration Form
OccupationalHealthandSafetyPrinciplesand
NursingCertificationReview
Name:____________________________________________________________
June18Ͳ208am—5:30pm(endsThursdayat2pm)
Company/Agency: ___________________________________________________
(Formoredetails,pleaseseehttp://www.ph.ucla.edu/erc/ohnreview-06-13.php )
Address __________________________________________________________
Faculty(subjecttomodification)
City: _____________________________________State: _______ Zip: ________
AnnetteB.Haag,MA,RN,COHNͲS/CM,FAAOHN
President,AnnetteB.HaagandAssociates,pastPresidentoftheAmericanAssociationof
OccupationalHealthNurses.Withover39yearsofexperience,sheisnationallyand
internationallyrecognizedinthefieldofhealthandsafety.
ElizabethThomas,PhD,RN
Dr.ThomasisanAssistantProfessorintheOccupationalandEnvironmentalHealthNursing
Program,UCLASchoolofNursing
WhoShouldAttend
DesignedforNurseswhoare:
x EmployedfullorpartͲtimeinthefieldofOccupationalHealth;
x PreparingforAmBoardofOccupationalHealthNursesCertificationExams—COHNor
COHNͲS;
x ConsideringenteringthefieldofOccupationalHealthNursing;
x SettingupOccupationalHealthPrograms
Job Title: __________________________ Department: _____________________
Daytime phone: __________________ Fax #: __________________
Cell #: _________________________
E-mail: ___________________________________________________________
Payment Amt $____________
Method of Payment: ___Check
___ Credit Card Type of Credit Card: _________
Name as it appears on card: ___________________________________________
Credit Card Number: ________________________________ Exp. Date ________
Billing Address:______________________________________________________
Signature: _________________________________________________________
Profession: __ Physician __Ind. Hygienist __ Nurse __ Safety or Other: ____________
Employer: ____Federal Gov. ____State Gov. ____Local Gov. ____ Academic
Valuableinformationfor:
•CaseManagers•RiskManagers•Workers'CompensationClaimsPersonnel
____Private Co. _____ NGO/Non-Profit ____Self-Employed ____Student
•SafetyConsultants•Physicians•Directors/AdministratorsofOccupationalHealthFacilities
Accreditation
ProviderapprovedbytheCaliforniaBoardofRegisteredNursing,Provider#13555(SCERC)for22.5(50Ͳ
minute)contacthoursand18.75(60Ͳminute)contacthours.
CourseLocation—UCLA
Parkinganddrivinginstructionswillbesentuponreceiptofyourregistration.
RegistrationInformation
PleaseseewebsiteͲwww.ph.ucla.edu/erc/ced.phpͲforpaymentterms
StandardFee:$795EarlyBird:(ends5/17/13)$645Feeincludescoursemanuals(2
inset),refreshments,Thursdaylunch,parking(freeifinstructionsarefollowed).
Payingbycreditcard:Allmajorcreditcardsaccepted.Completecreditcard
informationonregistrationformorcall310/206Ͳ2304.
Payingbycheck:PayabletoUniversityofCaliforniaRegents
Phoneregistration:310/206Ͳ2304Faxregistration:310/794Ͳ9317
Onlineregistration:www.ph.ucla.edu/erc/register.php
Lodging
UCLA Tiverton House, 900 Tiverton Avenue, Los Angeles, CA 90024-3013.
Reservations: 310/794-0151, http://www.tivertonhouse.ucla.edu/index.html Reservations are to be made directly with the Tiverton House.
UCLA Guest House. The Guest House is conveniently located on campus and
adjacent to campus shuttles. Telephone: 310/825-2923. Reservations are to be
made directly with the Guest House.
A list of additional hotels near campus will be sent upon request.
Southern California NIOSH Education & Research Center
UCLA School of Public Health
650 Charles E. Young Drive South, 61-279 CHS Los Angeles, CA 90095-1772
Phone: 310/206-2304 E-mail: erc@ph.ucla.edu
http://www.ph.ucla.edu/erc/ced.php