Free Certification Application - Individual Lead-Based Paint Activities & Investigations, DPH 44003 - Wisconsin

DEPARTMENT OF HEALTH & FAMILY SERVICES Division of Public Health DPH 44003 (Rev. 10/02)

STATE OF WISCONSIN Bureau of Occupational Health HFS 163, Wis. Adm. Code (608) 261-6876

CERTIFICATION APPLICATION ­ INDIVIDUAL LEAD-BASED PAINT ACTIVITIES & INVESTIGATIONS
Read Information and Instructions, DPH 44003I attached, before completing this form.

Interim Certification - Applying for Interim certification (For individuals who qualify prior to taking certification examination) Initial Certification - Applying for Initial certification Renewal Of Certification ­ Applying for renewal certification [current Department of Health & Family Services (DHFS) Certification Number

]

INDIVIDUAL INFORMATION
Name of Applicant (First, Middle, Last) include e.g. Jr., Sr., or III Mailing Address Gender Female Male Home Telephone Number ( ) Pager Number ( ) City Date of Birth (month / day / year) - minimum age 18 Fax Telephone Number ( ) Email Address Social Security Number State Height Zip + 4 Weight

Cellular Telephone Number ( )

COMPANY INFORMATION
Provide information about employer, or business if self-employed. If company is not certified, submit a lead company application. Company Name DHFS Lead Company Certification Number Mailing Address City State Zip+4

MANDATORY CERTIFICATION EXAM
Required for Lead Abatement Supervisor, Hazard Investigator, Inspector, or Risk Assessor certification. Information must be received at least two weeks before the scheduled exam for verification of eligibility and preparation of materials. Check the appropriate box(es). $50 registration fee enclosed. Requested exam location Madison Milwaukee (1 p.m. or 5 p.m.) Eau Claire by appointment Other location, date and time has been arranged for a group: Previously passed a certification exam and currently certified to work in another state. See regulatory worksheet instructions on page 2.

CERTIFICATION FEE
Check the discipline for which you are applying and check the fee enclosed. If a government employee fee exemption is requested, enclose supporting documentation. Write check or money order payable to DHFS. Check the web site www.wisconsin.gov or HFS 163, Wis. Adm. Code, for certification definitions. 1-Year 2-Year Initial/Interim2-Yr. RenewalDiscipline Initial/Interim Fees Renewal Renewal Gov't Employee Gov't Employee Lead-Safe Worker $50 N/A N/A 0 N/A Abatement Worker Abatement Supervisor Project Designer Sampling Technician Hazard Investigator Inspector Risk Assessor Replacement Card - $25 Enclosed fees paid by Employer Self Other $75 $125+$50 Exam=$175 $175 $50 $150+$50 Exam=$200 $150+$50 Exam=$200 $175+$50 Exam=$225 N/A $125 $175 N/A $150 $150 $175 $75 $225 $325 $50 $275 $275 $325 0 0+$50 Exam=$50 0 0 0+$50 Exam=$50 0+$50 Exam=$50 0+$50 Exam=$50 0 0 0 0 0 0 0

The certification card will be mailed to the individual's mailing address. Does the company want a courtesy copy of the certification card sent to the company's mailing address? Yes Fax Mail No For DHFS only. Old Expiration Date Check-in Data Entry Payment Date Paid This Application New Certification Expiration Date Data Check Total Payment New Training Due Card Print

DPH 44003 (Rev. 10/02) Page 2 Name of Applicant (First, Middle, Last)

TRAINING
Location (city / state) and date required training for this discipline was last completed (month / day / year) and name of training provider. Attach documentation if required.

OTHER LICENSES, REGISTRATIONS OR CERTIFICATIONS
Within the past 5 years, did you have a lead license, registration or certification issued by another state, Indian tribe or the U.S. Environmental Protection Agency? Yes No If yes, who issued it? Within the past 5 years, did you have a lead license; certification or registration denied, modified, suspended or revoked another state, Indian tribe or the U.S. Environmental Protection Agency? Yes No If yes, what action was taken, why and by whom? Within the past 5 years, was action taken against you for a civil or criminal violation of statutes, regulations or ordinances of the United States, in this state, any other state, or any local government substantially related to lead-based paint activities or other environmental activities? Yes No

If yes, what action was taken, why and by whom?

AFFIDAVIT OF APPLICANT
I state that I am the person referred to on this application and that all the answers set forth are strictly true in each respect. I understand that false or forged statements made in connection with this application may be grounds for denying or revoking my certification or for other disciplinary or legal action. I also understand that if I am issued a certification card, failure to comply with the laws or rules of the State of Wisconsin may be cause for disciplinary or legal action. SIGNATURE ­ Applicant Date Signed (mm/dd/yy)

ATTACHMENTS
For all applications, applicant must check that the following materials are attached and submitted with the application form. Education and Experience Qualification Affidavit (page 3 of the application) - required for Lead Abatement Supervisor, Hazard Investigator, Project Designer, or Risk Assessor certification. Photo, passport style. Shoulders and face must be 2" x 2" and applicant's face must be clearly recognizable. Digital photos may be emailed as jpeg files to [email protected] . In the subject line, state "Application", followed by the applicant's name and DHFS certification number, if already assigned. (Example: Application-John Doe, LCS-1234) Printed photo attached Digital photo emailed from:_____________________________________________________________________________________ Copy of all applicable lead training certificate(s) not previously submitted. (A DHFS-accredited trainer will submit this information if you attended their training.) Check or money order payable to DHFS. In addition, for an application for initial or interim certification, applicant must check that the following are attached: Official photo identification and verification of birth date. Copy of X-Ray Fluorescence (XRF) training certificate - required for Lead Inspector or Risk Assessor certification. Regulatory worksheet, copy of current certification to work in another state, and proof of passing an authorized certification exam ­ required for Lead Abatement Supervisor, Hazard Investigator, Inspector, or Risk Assessor certification if not registering for the mandatory certification exam. Lead company application, if not already certified. If you have questions please call (608) 261-6876. If mailing, use the Mailing Address listed below. Applications may be hand delivered to the Street Address. Return completed application to: Mailing Address Department of Health and Family Services Asbestos and Lead Section, Rm 137 P.O. Box 2659 Madison WI 53701-2659 Street Address Department of Health and Family Services Asbestos and Lead Section One West Wilson Street, Room 137 Madison WI 53703

DPH 44003 (Rev. 10/02) Page 3

EDUCATION AND EXPERIENCE QUALIFICATION AFFIDAVIT: For Lead Abatement Supervisor, Hazard Investigator, Project Designer, or Risk Assessor Applicant
Name of Applicant (First, Middle, Last) include e.g. Jr., Sr., or III

EDUCATION
Specify in which field a degree has been earned. Documentation does not have to be submitted with this form, but must be provided for review by DHFS staff upon request. Type of school High School Technical College College Other EXPERIENCE Paid and unpaid experience in lead, asbestos, or environmental remediation work, building maintenance or construction. You must clearly describe your experience and be prepared to submit documents upon request by the Department of Health and Family Services. The documents should detail your experience related to lead, asbestos, or environmental remediation work, building maintenance or construction, such as your resume, letters from employer(s) that describe your job and length of experience, letters from people knowledgeable about your experience, copies of inspection reports you prepared, copies of related certifications you hold. Employer / Organization Start (month/year) End (month/year) Description of work or experience Name of school Start month/year End month/year Diploma / Degree, or hours / credits earned if none awarded

OTHER PROFESSIONAL CERTIFICATION
For certification as a lead hazard investigator or risk assessor, you may document qualifications through professional certification as an industrial hygienist, professional engineer, registered architect, or professional certification in a related professional engineering, health or environmental field, such as safety professional or environmental scientist. You may also document qualifications as a registered nurse or registered sanitarian employed by a health department that provides oversight of your activities. Attach a copy of documents that verify your professional certification. Type of Certification / Registration Start (month/year) Expiration (month/year) Certifying Agency / Organization

AFFIDAVIT OF TRUTHFUL STATEMENTS
I state that I am the person referred to on this affidavit. I further affirm by my signature that all statements I have made regarding my education and experience are true. I understand that false or forged statements made in connection with this affidavit may be grounds for denial or revocation of my certification or other disciplinary or legal action. If requested by DHFS staff, I will provide documentation to verify I meet the required qualifications as I have stated on this form. SIGNATURE ­ Applicant Date Signed (mm/dd/yy)

DEPARTMENT OF HEALTH AND FAMILY SERVICE Division of Public Health DPH 44003I (10/02)

STATE OF WISCONSIN Bureau of Occupational Health HFS 163, Wis. Adm. Code (608) 261-6876

CERTIFICATION APPLICATION ­ INDIVIDUAL
LEAD-BASED PAINT ACTIVITIES & INVESTIGATIONS INFORMATION & INSTRUCTIONS
Personally identifiable information collected on this application will be used to determine eligibility for certification. The information may be shared with other governmental agencies as part of enforcement activities. Since information may also be available under an open record request, you may choose to provide a work address and telephone number instead of home information. Under sections 250.041 and 254.115, Wis. Stats., an individual must provide his or her Social Security Number and a company must provide the company's Federal Employer Identification Number to be certified. The Social Security Number (SSN) may be used to deny or revoke certification of persons delinquent on payment of taxes or child support and will not be available to the public. If self employed, you must provide the name under which you do business. The application must be completed neatly and accurately. An incomplete application will be returned without processing. Allow 10 working days for processing. Applications are processed in the order they are received. CERTIFICATION Interim Certification - Check this box if you are qualified to take the certification examination but are not yet eligible for the initial certification, and you are applying for Lead Abatement Supervisor, Hazard Investigator, Inspector, or Risk Assessor certification. You may request interim certification if you completed initial or refresher training within the past 6 months and have not held interim certification in the past. This allows you to work before you pass the certification exam. Interim certification expires 6 months after the last date training was completed. Initial Certification - Check this box if applying for the first certification in this discipline from the Department of Health and Family Services (DHFS) and do not qualify for interim certification. Also check this box if there has been a lapse in your certification of 12 months or more. Renewal Certification - Check this box if you are applying for a renewal certification and include your DHFS Certification number. INDIVIDUAL INFORMATION Mailing address - This is the address where your certification card and renewal notice will be mailed. You are required to notify us when your mailing address changes. However, if you move frequently, you may want to use your employer's mailing address. Home, Fax, Cellular Telephone, and Pager Numbers; & Email Address - If you have these available, print them in the space provided on the application. DHFS will contact these numbers if questions arise while processing the application. COMPANY INFORMATION - Provide the name of your employer or, if self-employed, the name of the business under which you perform lead-based paint activities or lead investigation activities. To help us associate your information with the correct company, also provide the DHFS lead company certification number. You must own, be employed by, or otherwise affiliated with a certified lead company before you perform lead abatement or lead investigation activities. MANDATORY CERTIFICATION EXAM - If you are applying for Lead Abatement Supervisor, Hazard Investigator, Inspector, or Risk Assessor initial or interim certification, you must register for a mandatory State-administered certification exam and add $50 to the certification fee. The certification exam fee is not refundable. Documentation instead of State Certification Exam - You do not have to take the Wisconsin certification exam if you previously passed a qualified certification exam offered by EPA, another state, or an Indian tribe, and are currently certified to work in another state. However, you must enclose proof of passing the exam and a copy of your current certification to work in that state. In addition, you must complete and submit a regulatory worksheet to demonstrate knowledge of Wisconsin lead regulations under ch. HFS 163, Wis. Adm. Code. To request a copy of the worksheet and regulations, contact the Asbestos and Lead Section. CERTIFICATION FEE - Enclose a check or money order payable to the Department of Health and Family Services or DHFS. Cash is not an acceptable form of payment. The initial certification fee may not be refunded or prorated. DHFS charges a fee for checks not honored by the bank. Check the web site www.wisconsin.gov or HFS 163, Wis. Adm. Code, for certification definitions. Important Note: You may be exempt from paying certification fees if you are employed by a state or local government and need to be certified to perform your job duties. If claiming a fee exemption, enclose documentation that clearly establishes eligibility for this exemption, e.g. a letter from your supervisor on official letterhead that explains why certification is needed to perform your duties. TRAINING - First-time applicants must submit a complete training history, including copies of all required initial and refresher lead training certificates for the discipline. To re-certify, submit information on training completed since your last application. Be sure to keep your original training certificates in case you ever have to prove your training again. X-Ray Fluorescence (XRF) Training - Effective March 1, 2002, all interim, initial, and renewal Lead Inspector and Risk Assessor applications must include proof that the applicant completed XRF training under ch. HFS 157, Wis. Adm. Code. This training may be offered by an XRF manufacturer or by another qualified training provider. DHFS-accredited completed on or after March 1, 2002 - The DHFS-accredited training provider will submit your training certificate information directly to DHFS. To be sure your application is correctly linked to your most recent training for this discipline, provide the training dates and the name of the training provider on the application. DHFS-accredited training completed before March 1, 2002 - Either the original training certificate or a photocopy of the training certificate, notarized as a true copy of the original training certificate, must be submitted as proof of completing training. We will copy and return all original training certificates to you with your new certification card. Out-of-state training not accredited by DHFS - the original training certificate must be submitted. We will copy and return all original training certificates to you with your new certification card. OTHER LICENSES, REGISTRATIONS OR CERTIFICATIONS - You (the applicant) must personally answer all three questions.

DPH 44003I (Rev. 10/02) Page 2 AFFIDAVT OF APPLICANT - You (the applicant) must personally sign and date the affidavit. EDUCATION AND EXPERIENCE QUALIFICATION AFFIDAVIT - If applying for Lead Abatement Supervisor, Hazard Investigator, Project Designer, or Risk Assessor certification, you must meet one of the following additional qualifications for your discipline. If you meet one of the minimum qualifications listed below, you (the applicant) must complete and personally sign the Education and Experience Qualification Affidavit on page 3 of the application. (If applying for certification in another discipline, do not submit the Education and Experience Qualification Affidavit.) Lead Abatement Supervisor (one is required) One year of experience as a certified lead abatement worker or lead abatement supervisor. At least 2 years of experience in a related field. (e.g. lead, asbestos, or other environmental remediation work, building maintenance or construction.) Lead Risk Assessor or Hazard Investigator (one is required) Bachelor's degree or higher and 1 year experience in a related field (e.g., construction, lead, asbestos, or environmental remediation work). Associate's degree and 2 years experience in a related field (e.g., construction, lead, asbestos, or environmental remediation work). A high school diploma, or equivalent, and at least 3 years experience in a related field (e.g., construction, lead, asbestos, or environmental remediation work). Certification as an industrial hygienist, professional engineer, registered architect, or certification in a related engineering, health, or environmental field, based on a minimum of a 4-year college degree (e.g., safety professional or environmental scientist). Registered nurse or registered sanitarian employed by a health department that provides oversight of your activities Lead Project Designer (one is required) Bachelor's degree or higher in engineering, architecture, or a related profession and 1 year experience in building construction and design or a related construction field; Four years experience in building construction and design or a related construction field. ATTACHMENTS - Before submitting the application, check that you have included all of the required attachments listed on page 2 of the application. Photograph - For your photo-ID certification card, enclose a recent passport-style photo that clearly shows your face, with the size of the face and shoulders being approximately 2" x 2". Your photo may be self-developing, but not a photocopy, digital picture printed on bond paper, nor picture in plastic. Digital photos may be emailed as jpeg files to [email protected] . In the subject line of your email, state "Application", followed by the applicant's name and DHFS certification #, if already assigned. (Application-John Doe, LCS-1234) Under ATTACHMENTS on page 2 of the application, provide the name of person submitting the digital photo. If your training provider takes a digital photo when you take the refresher course, you do not have to submit a photo at this time. However, provide the name of the training provider under ATTACHMENTS on page 2 of the application. Verification of date of birth and photo identification - Submit a copy of your driver license or other official photo identification and proof of date of birth with the first application. The minimum age for certification is 18. Regulatory worksheet - There is a separate regulatory worksheet for Lead Abatement Supervisors and Lead Inspectors and one worksheet for Lead Risk Assessors and Hazard Investigators. You (the applicant) must personally complete the worksheet by printing or handwriting the answer as found in ch. HFS 163, Wis. Admin. Code. You also must personally sign the worksheet. You must submit the original - not a photocopy - of the completed form. If you have, any questions call (608) 261-6876. If mailing, use the U.S. Post Office Mailing Address listed below. Applications may be hand delivered to the Street Address. Mailing Address Street Address Department of Health and Family Services Department of Health and Family Services Asbestos and Lead Section, Rm 137 Asbestos and Lead Section P.O. Box 2659 One West Wilson Street, Room 137 Madison WI 53701-2659 Madison WI 53703 Allow 10 working days, from the date of receipt, for processing. Applications are processed in the order they are received. Hand delivered applications will not be processed at that time. Incomplete application materials will not be processed. If you have a new address or employer after obtaining certification, forward this information as soon as possible to the Bureau of Occupational Health, Asbestos and Lead Section, Rm 137, P.O. Box 2659, Madison, WI 53701-2659 or to [email protected] .