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SHIP SANITATION INSPECTION AND ISSUANCE

OF SHIP SANITATION CERTIFICATE LEARNING PROGRAMME

Please fill in this form and send it back to

Thank you in advance.

Please type the form

REQUEST FORM

Requesting organization: ______
Person in charge of the request: ______
(First & Last Names)
Title: ______Function: ______
Full address: ______
Zip code: ______City: ______Country: ______
Business tel. number: ______Mobile tel. number: ______
Email: ______Web site: ______/ Internal use only:

Background information in support of the request:

(description of organization activities related to ship sanitation inspection)

Please complete the questionnaire below and check the appropriate boxes:

Nature of the request

This training is intended for

□ a local port

□ national coverage

Additional anticipated training needs at national level (please describe):

Which component of the Learning Programme are you going to use:

□ Standard package

  • e-learning
  • face-to-face

-facilitator’s guide

-user’s manual

  • briefing of course manager

□ Customized package(to be defined on a case-by-case basis)

Would your organization be willing to accept (a) Public Health Officer(s) from another country in this learning programme(s)

□ Yes□ No

Would your organization be willing to provide an expert Public Health Officer to support the implementation of the learning programme in other countries?

□ Yes□ No

Level of support from WHO

Number of people who will benefit from this initiative:

□ 1 to 5 / □ 10 to 15 / □ 20 to 25
□ 6 to 10 / □ 16 to 20 / □ above 25

Do you anticipate *support from WHO in implementation of face-to-face activities (e.g. training facilitation)? *Please note that when WHO support is requested, we will coordinate with the relevant WHO regional office.

□ Yes□ No

Anticipated starting date considered for implementation for*e-learning prior to the face-to-face course:

*It is recommended that you launch the e-learning course 6 weeks prior to the face-to-face course.

day/month/year

---- /------/------

Language:

□ English □ French □ Portuguese □ Russian

□ Spanish □ Turkish □ Other(s) (please specify): ______

I confirm that I have read the purpose and objectives of the Learning Programme described here

Signature: ______

(signature should be handwritten)

ANNEX 1

Access to the E-learning is individualized. Fill in and return the attached Annex 1 to WHO

WHO will then process the request and provide access to each individual listed.

Please type the form

Name of requesting organization / Name of person responsible for implementation of the Learning Program (Course Manager)
List of individuals who will participate:
Last Name / First Name / Gender
F / M / Work title (position in the organization) / Country / Email address