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* 1. First Name:

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* 2. Last Name:

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* 3. Title:

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* 4. Agency/Organization: (No Abbreviations)

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* 5. Email Address:

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* 6. Mailing Address: (for course materials)

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* 7. Phone number:

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* 8. How long at current title?

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* 9. Has your supervisor approved you to attend this course?

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* 10. Supervisor Name:

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* 11. Supervisor Email Address:

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* 12. Supervisor Phone Number:

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* 13. Have you taken an instructor skills or similar type training? 

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* 14. If yes, what training(s) have you attended?

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* 15. Have you had a facilitation role in a Process Improvement project?

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* 16. If yes, please describe the project(s).

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* 17. Do you have any experience with Lean, Six Sigma, or other quality improvement models?

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* 18. If yes, please indicate your experience.

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* 19. Are there projects your agency is currently working on or looking at that could benefit from you attending this Process Improvement Course?

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* 20. If yes, please list them. 

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* 21. Does your computer have microphone and camera capabilities?

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