Registration Form
Complete the following form to create an account for use inside the campus. The information collected here will not be shared with any third-party and is used solely for providing services inside the campus.
What would you like to do ? Register and receive an accountUpdate my information
How did you hear about us ? Email from NCBRT Email - Other Flyer ICSC NCBRT Class NCBRT Website University program University of Minnesota: Disaster 101 Other
Participant Information
* First Name:
* Last Name:
Middle Initial:
Suffix: BC BS BSN CCRN CEN CFA CPA CSP CST DDS DMD DO DPT DVM EdD EMT B EMT I EMT P I II III IV JD Jr LPN LVN MA MBA MD MPA MPH MS MSN PA C PhD RDA RN SPC Sr V VMD
* Title ⁄ Rank Position:
Agency Information
* Agency,University,Association or Company Name: * If you do not have an agency or company, please specify "N/A" for Agency Name and provide personal contact information below.
* Address:
* City:
* State: AK AL AP APO AR AZ CA CO CT DC DE FL FP GA GU HI IA ID IL IN KS KY LA MA MD ME MI MN MO MP MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR RI SC SD TN TX UT VA VAUD VI VT WA WI WV WY
* Zip Code:
County:
If non-US, specify the country:
* Phone #: Type: Work Home Mobile Work Alt Home Alt Personal Mobile
* Number:
Extension:
Fax:
* Email Address:
* Verify Email Address:
Mailing Address: Check if same as work address
City:
State: AK AL AP APO AR AZ CA CO CT DC DE FL FP GA GU HI IA ID IL IN KS KY LA MA MD ME MI MN MO MP MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR RI SC SD TN TX UT VA VAUD VI VT WA WI WV WY
Zip Code:
Experience as a Trainer / Instructor - (please select ALL items that apply)
Conducted training within Department/AgencyConducted training for other Departments/Agencies
Years of Job Experience
Years in Profession:
Years in Agency:
Type of Department ⁄ Agency — Select one item that is most similar to the agency ⁄ company you represent.
* Agriculture Related Airport Authority Ambulance Service Emergency Management Agency Emergency Medical Fire Department Funeral Home Hospital National Guard Other Other Gov't Agency - Federal Other Gov't Agency - Local Other Gov't Agency - State Police Department Port Authority Private Industry/Sector Public Health Public Works Ranger Station Rescue Squad School District Search and Rescue Sheriff's Office State Police University Volunteer Fire Department
Area of Jurisdiction - Select one item best describing your agency's affiliation.
* Airport Campus City County/Parish District of Columbia District/Region Federal Federal DHS Federal Non DHS Local Metro National Other Port State Township Tribal Territory US Territory
Job Duties - Select one item for your primary job duty.
* Agricultural Distributor Agricultural Extension Agent Agricultural Processor Agricultural Producer Airport Operations Appointed Public Official Campus Law Enforcement Citizen/Community Volunteer Disaster Board Member Elected Official Emergency Management EMS Explosive Ordnance Disposal Fire Suppression Governmental Administrative HazMat Higher Education Hospital Administrator Hospital Planner Information Technology Jurisdiction/Government Lab Technician Law Enforcement Military Nurse Other Other Health Care (Non-EMS) Physician Private Sector Public Health Public Safety Communications Public Works Safety Officer Search & Rescue Security Transportation Security Veterinarian
Professional Background - Select one item which best describes your background.
Agency Head Elected Official Emergency Responder Line Supervisor Senior Management Volunteer
WMD Background - Select all items below which best describe your background.
No prior training/experienceSubject Matter Expert - Local levelInvolved in development of agency/jurisdiction WMD planAwareness trainingSubject Matter Expert - State levelWork in specialized HazMat or explosive ordnance disposal unitSeveral Courses (2-4)Subject Matter Expert - Federal levelServe on WMD Task ForceExtensive Training (5+ courses) Other:
Eligibility
I have reviewed the necessary requirements for this training (in Course Descriptions ) and I certify that I meet these requirements.
If No, please explain:
I certify that I meet the U.S. citizen requirement.
I am willing to participate in a post-class evaluation consisting of a phone call or email to help the NCBRT make improvements to classes and collect feedback on how course information is being applied in the field.*
By submitting your registration information, you indicate that you agree to the Terms of Use and have read and understand the NCBRT eLearning Privacy Policy.
Business hours disclaimer:
Regular business hours are Monday through Friday, 7:00 am to 4:30 pm (Central time). Requests made on weekends, holidays, and/or outside of regular business hours will be addressed as soon as possible.
Citizenship disclaimer:
Participation is currently limited to United States citizens unless a special request form is completed. Once the form is reviewed, you will be notified via email the status of your account.
*Confidentiality of Information:
The training evaluation forms have been designed to solicit your assessment of enhanced knowledge and skills related to the course objectives and any actions you plan to take to enhance your capacity or that of your agency to respond to a terrorist attack. The information will be used by the Department of Homeland Security — FEMA to modify or enhance the training course to better meet the needs of emergency responders and to address changing terrorist threats. Although your feedback is very important to us, completion of the form or specific questions is voluntary. The personal identifying information is requested so that we can conduct a follow-up survey on the usefulness of the course to you. Your responses and all personal information will remain confidential. Any reporting of the data will be done anonymously in an aggregated fashion, without names or identifiers.
Public Reporting Burden:
Paperwork Reduction Act Notice. Under the Paperwork Reduction Act, a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. We try to create forms and instructions that are accurate, can easily be understood, and which impose the least possible burden on you to provide us with information. The estimated average time to complete and file this application is 15 minutes per form. If you have comments regarding the accuracy of this estimation, or suggestions for making this form simpler, you can write to the Office for Domestic Preparedness, 810 7th Street, N.W., Washington DC, 20531.