1.First Name:

2.Last Name:

3.Title:

4.Agency/Organization: (No Abbreviations)

5.Email Address:

6.Mailing Address: (for course materials)

7.Phone number:

8.How long at current title?

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

Yes

No

10.Supervisor Name:

11.Supervisor Email Address:

12.Supervisor Phone Number:

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

Yes

No

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

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

Yes

No

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

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

Yes

No

18.If yes, please indicate your experience.

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

Yes

No

20.If yes, please list them. 

21.Does your computer have microphone and camera capabilities?

Yes

No