Application for Certification/Recertification
CAOHC Course Director

All information marked with an asterisk (*) must be provided in order for CAOHC to accept this application. Online submissions will not go through if these fields are not complete. To submit this form by fax or mail, simply print it out, include copies of all required documents and fax or mail it, with payment, to the address at the bottom of this form, ATTN: Education Manager.

  

Work Address

Home Address

Telephone Number

Professional Information

A.  Indicate your current certification by any of the following educational/professional certifying boards.*

B.  Indicate your current membership in any of the following professional organizations:*

C.  Provide current professional licensure or registrations, with dates awarded. Must be Licensed in the United States for the practice of medicine, nursing or audiology or have a current membership in The American Industrial Hygiene Association, Institute of Noise Control Engineering, or the American Society of Safety Engineers.

D.  Provide any additional comments which you feel would be helpful to CAOHC in considering your application.

Other equivalent certification may be considered but must be approved by CAOHC council members prior to attending a workshop. Applicants from outside the United States who do not meet one of these criteria must meet the requirements of their local jurisdictions for professional practice, and are subject to approval by the CAOHC Council.

E.  Submit verification of work experience. (Certifying only)

Applicants must fulfill at least one of these requirements:

  • A minimum of one year equivalent (1,000 hours) work experience in occupational hearing conservation activities, within the past five years. (Documentation is required in the form of a Verification Letter from a Supervisor outlining experience and number of hours devoted exclusively to OHC in the past 5 years. If applicant managed their own business or didn't work with a supervisor, they should contact the CAOHC administrative office for additional instructions.)
  • Participation as adjunct faculty and practicum assist under the direct supervision of a CAOHC-approved Course Director (CD) for one 20-hour course including all responsibilities per the Course Director Policies & Procedures listing. (Documentation is required in the form of a Verification Letter from the Course Director.)

Terms and Conditions

If you are submitting online, you MUST read the following and agree by checking this box BEFORE you submit your application.

  1. I agree that CAOHC may verify any information provided in this application by contacting listed employers, educational institutions, or clients.
  2. I understand and accept that CAOHC may from time to time impose additional requirements for courses and Course Directors, and that my continued tenure as a Course Director will require my compliance with those requirements.
  3. I understand and accept that although Course Director certification is ordinarily valid for a five-year term, this certification can be revoked for failure to comply with CAOHC requirements, including those enumerated above.

Signature (if submitting by mail or fax):___________________________________________

Date: ____________

Workshop Registration

Workshop Information

Cancellation Policy
Seven days prior to the workshop, a full refund will be made to any registrant who must cancel his/her attendance, with the exception of a $25 processing fee. After 7 days prior to the workshop, no refund will be made.

Attendance Policy
Candidates must be present for the entire course in order to be granted certification, recertification, and CEU credits.

Registration Information


How did you hear about the workshop?

Payment Information

$125.00

All information marked with an asterisk (*) must be provided in order for CAOHC to accept this application. Online submissions will not go through if these fields are not complete. To submit this form by fax or mail, simply print it out, include copies of all required documents and fax or mail it, with payment, to the address at the bottom of this form, ATTN: Education Manager.



FOR OFFICE USE ONLY: 
  Rec'd @ CAOHC Office:

Signature: __________________________________________ Date: ____________