Training Roster Template
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1
2OTDA 4869 (Rev. 1/2014) FRONT
NEW YORK STATE
OFFICE OF TEMPORARY AND DISABILITY ASSISTANCE
TRAINING ROSTER
Page
of
CONTRACT PROVIDER
COURSE IDENTIFIER/NUMBER
NAME OF COURSE
TOTAL NUMBER OF CLASS HOURS
SUNY Albany-PDP
SNAP Civil Rights Training (webcast)
1.0
COURSE LOCATION
INSTRUCTOR(S)
START DATE
END DATE
NOTE: Instructors are responsible for ensuring that all items are fully completed by the trainees. The information MUST be provided in an accurate and legible manner
.
To Be Completed By
Reverse For Codes
Instructor
TRAINEE NAME
Email Address
POSITION (JOB
AGENCY/FACILITY
(Please Print)
TITLE)
NAME (e.g. NYS OTDA,
Albany County DSS,
And/or
Baker Hall, Tryon
Residential)
Last Name
First Name
Agency/Facility Phone Number
2
1
13
1
DOE
JANE
Jane.Doe@otda.ny.gov
Contract
NYS
(518) 555-1234
Mgmt Spec
OTDA
INSTRUCTOR(S) REMARKS:
CERTIFICATES REQUESTE
ISSUED:
INSTRUCTOR SIGNATURE REQUIRED:
DATE:
YES
NO
x
____________________________________________________
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