Office of Human Resources
Registration Form
PRINCIPLES OF EPIDEMIOLOGY
Missouri Department of Health & Senior Services,
930 Wildwood Drive, Jefferson City
To register, complete the following form and e-mail to diana.winder@health. or fax to 573-526-0234.
First Name: Last Name:
Job Title: Years or Months in this Position:
What is your primary role?
Local Public Health Agency/Division:
Section/Bureau, if applicable:
Mailing Address (work):
City: State: Zip:
If within Jefferson City, please include inter-agency mailing address:
Phone (include area code):
Email Address:
Name of Supervisor:
My supervisor has been made aware of and has given permission for my enrollment in this course.
I would like to attend the following course:
March 7 - 8 June 6 - 7 September 12 – 13
Yes, I do have a laptop computer to bring to class
No, I do NOT have a laptop computer to bring to class
I plan to attend the half-day Introduction to EpiInfo 7 from 1 pm – 5 pm the afternoon prior to the workshop I have registered for (Contact Diana Winder at (573) 526-5832 for more information).
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If you will need any accommodations in compliance with the Americans with Disabilities Act, please contact the Bureau of Communicable Disease Control and Prevention at 573-751-6268.
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