Select the Highway Safety Day date and location for which you would like to register.  If you need to register for an additional location, you will need to submit another registration form and will be prompted at the end of the registration process. *


 
What is the name of your county/municipality?

 
To whom should we send Highway Safety Day correspondence, audiometric test results, and MSHA certification sheets?

 
Please provide a phone number for the contact listed above.

 
Is the contact listed above the Highway Commissioner/Director of Public Works?

     
 
Please provide the name of the Highway Commissioner/Director of Public Works.

 
Please provide a phone number for the Highway Commissioner/Director of Public Works.

 
The County Mutual is able to offer MSHA Annual Refresher cards for Highway Safety Day attendees taking part in the full 7.5 hours of training. The Miner's Rights training must be attended for attendees to receive the cards. For attendees who require MSHA Part 46 New Miner Training, a list of available courses can be found, here: https://dsps.wi.gov/Pages/Programs/MineSafety/Default.aspx

 
This year we will be offering an option for attendees to take either Miner's Rights OR Work Zone Safety (except Crandon - only Miner's Rights). For an employee to receive a MSHA Annual Refresher card from the County Mutual, you will need to register the employee for Miner's Rights.

 
Please provide the requested information below. We will ask for the total number of attendees you would like to register as well as the names of attendees who will register for Miner's Rights (#17) and Work Zone Safety (#18), separately.

 
How many attendees would you like to register?

You will be asked to provide the full names of each attendee to properly generate MSHA Annual Refresher cards.
 
Will all attendees take part in annual audiogram testing?

     
 
How many will take part in annual audiogram testing?

 
Will all attendees take part in the Miner's Rights session?

     
 
How many will take part in the Miner's Rights session?

 
How many will take part in Work Zone Safety?

 
If you have a MSHA Training Plan, please upload by selecting the button below. A sample MSHA Part 46 Training Plan can be found here: https://arlweb.msha.gov/TRAINING/PART46/PT46TRAIN.htm

 
Please provide the FULL name (including FULL middle name) of each attendee taking part in the Miner's Rights session.  Please ensure correct spelling - your entries will be used on attendee MSHA Annual Refresher cards.  Approximately 14 days prior to the Highway Safety Day you will receive a list containing each attendee you've registered.

When complete, please scroll down to question #18 (following Attendee 75).
 
Attendee 1

 
Attendee 2

 
Attendee 3

 
Attendee 4

 
Attendee 5

 
Attendee 6

 
Attendee 7

 
Attendee 8

 
Attendee 9

 
Attendee 10

 
Attendee 11

 
Attendee 12

 
Attendee 13

 
Attendee 14

 
Attendee 15

 
Attendee 16

 
Attendee 17

 
Attendee 18

 
Attendee 19

 
Attendee 20

 
Attendee 21

 
Attendee 22

 
Attendee 23

 
Attendee 24

 
Attendee 25

 
Attendee 26

 
Attendee 27

 
Attendee 28

 
Attendee 29

 
Attendee 30

 
Attendee 31

 
Attendee 32

 
Attendee 33

 
Attendee 34

 
Attendee 35

 
Attendee 36

 
Attendee 37

 
Attendee 38

 
Attendee 39

 
Attendee 40

 
Attendee 41

 
Attendee 42

 
Attendee 43

 
Attendee 44

 
Attendee 45

 
Attendee 46

 
Attendee 47

 
Attendee 48

 
Attendee 49

 
Attendee 50

 
Attendee 51

 
Attendee 52

 
Attendee 53

 
Attendee 54

 
Attendee 55

 
Attendee 56

 
Attendee 57

 
Attendee 58

 
Attendee 59

 
Attendee 60

 
Attendee 61

 
Attendee 62

 
Attendee 63

 
Attendee 64

 
Attendee 65

 
Attendee 66

 
Attendee 67

 
Attendee 68

 
Attendee 69

 
Attendee 70

 
Attendee 71

 
Attendee 72

 
Attendee 73

 
Attendee 74

 
Attendee 75

 
Please provide the full name of each attendee taking part in the Work Zone Safety session. These attendees will NOT receive a MSHA Annual Refresher card from the County Mutual. If all of your attendees will be taking part in Miner's Rights, please scroll down to submit your registration.

When complete, please scroll down to submit this registration.
 
Attendee 1

 
Attendee 2

 
Attendee 3

 
Attendee 4

 
Attendee 5

 
Attendee 6

 
Attendee 7

 
Attendee 8

 
Attendee 9

 
Attendee 10

 
Attendee 11

 
Attendee 12

 
Attendee 13

 
Attendee 14

 
Attendee 15

 
Attendee 16

 
Attendee 17

 
Attendee 18

 
Attendee 19

 
Attendee 20

 
Attendee 21

 
Attendee 22

 
Attendee 23

 
Attendee 24

 
Attendee 25

 
Attendee 26

 
Attendee 27

 
Attendee 28

 
Attendee 29

 
Attendee 30

 
Attendee 31

 
Attendee 32

 
Attendee 33

 
Attendee 34

 
Attendee 35

 
Attendee 36

 
Attendee 37

 
Attendee 38

 
Attendee 39

 
Attendee 40

 
Attendee 41

 
Attendee 42

 
Attendee 43

 
Attendee 44

 
Attendee 45

 
Attendee 46

 
Attendee 47

 
Attendee 48

 
Attendee 49

 
Attendee 50

 
Attendee 51

 
Attendee 52

 
Attendee 53

 
Attendee 54

 
Attendee 55

 
Attendee 56

 
Attendee 57

 
Attendee 58

 
Attendee 59

 
Attendee 60

 
Attendee 61

 
Attendee 62

 
Attendee 63

 
Attendee 64

 
Attendee 65

 
Attendee 66

 
Attendee 67

 
Attendee 68

 
Attendee 69

 
Attendee 70

 
Attendee 71

 
Attendee 72

 
Attendee 73

 
Attendee 74

 
Attendee 75

Thank you, {{answer_tJpmUaNK3nY8}} for registering for the 2018 Highway Safety Days!  You've registered for the following date and location {{answer_dNG60SDUkiWn}}.  We look forward to seeing you and your employees!

If you need to make changes to this registration, please contact Jodi Traas at jodi@aegis-wi.com 800.511.9797.
Register At Another Location?
Powered by Typeform
Powered by Typeform