Last Name

First Name

Middle Initial(s)

Mailing Address

Email Address

Institution of employment

Telephone number

What is your profession?

Work setting Work setting Public Sector Private Sector Both Public and Private Sectors

How will payment be made? How will payment be made? By employer (Purchase order; cheque) By cash or major debit/credit card using Point of Sale machine at the Offices of Para Caribe Consulting, 11 Cunningham Avenue, Kingston 6, Jamaica By Manager’s cheque (group or individual) By direct deposit to bank account (please request invoice for banking information) By online transfer to bank account (please request invoice for banking information) Online via our website payment portal

By when do you intend to do the Certification in Infection Control examination? By when do you intend to do the Certification in Infection Control examination? Within 3 months from now 3-6 months 6-9 months 9-12 months More than 12 months

Have you ever done the US Certification Board in Infection Control and Epidemiology examination? Have you ever done the US Certification Board in Infection Control and Epidemiology examination? Yes No

Do you have at least an undergraduate degree from an established post-secondary educational institution? Do you have at least an undergraduate degree from an established post-secondary educational institution? Yes No

What is the highest level of education you have attained?

Are you part of an Infection Control Committee for your organisation? Are you part of an Infection Control Committee for your organisation? Yes No

If an Infection Control Committee member, for how long have you been a part of this committee? If an Infection Control Committee member, for how long have you been a part of this committee? Yes No

Do you personally have a copy of your formal written job description at your place of employment? Do you personally have a copy of your formal written job description at your place of employment? Yes No No, but able to obtain.

Which of the following activities are you currently involved in for your organisation? Which of the following activities are you currently involved in for your organisation? Providing medical care or preventive care for employees in your organisation Teaching Research Helping to identify new cases and track individuals with infectious diseases Management or leadership role in your organisation Cleaning, sterilisation, and disinfection. None of these currently.