Disaster Site Worker Course #7600 Outreach Training Report
End Date of Course: _____ / _____ / _____
Number of Students: _________ (List students’ names on back, or on a separate sheet)
Primary Trainer Course Information
_____________
ID Number*
_______________________________________
Name
____ / ____ / ____
Expiration Date
*ID number – new trainers do not have - only applies to trainers who have received student cards
Address - cards will be sent here: (If you have an ID number and your address is the same, you don’t need to complete this)
Check if this is a new address
Company / Dept.
Address
City /State /Zip
Phone No:
(_____) - _____ - _______ ext. ______
Best time(s) to
call:
Your documentation must include these items:
Disaster Site Worker Outreach Training Program Report – including
complete Training Certifications and Information section.
Student names
A copy of your course certificate or trainer card if you do not have
an ID#
Do not include these items with your documentation:
Student evaluation forms
Student sign-in sheets from each day of the course
Training Certifications and Information
_____ (Check) I certify that I taught all the required topics and met the Lesson Objectives of the Disaster Site Worker Course #7600.
_____ (Check) I certify that I conducted the training for a minimum of 16 hours.
_____ (Check) I certify that I have maintained supporting documentation on the respirator performance checklists and scores.
The range of scores that I recorded for the Operations Performance Score in the respiratory protection performance test: FROM ________ TO ________
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