DEPARTMENT OF HEALTH SERVICES Division of Public Health F-00047 (03/09) Page 1 of 2
STATE OF WISCONSIN Bureau of Environmental and Occupational Health DHS 159, Wis. Adm. Code
DESIGNATED ASBESTOS COORDINATOR
(Local Education Agency)
Personally identifiable information necessary for processing this application and collected on this application may be shared with other government agencies and may also be available under an open records request by the public.
LOCAL EDUCATION AGENCY (LEA) INFORMATION (Provide contact information for the local education agency)
Annual contact information report Original report Reporting change of contact information LEA Name Mailing Address City Name of Administrator or Superintendent Work Telephone No. ( ) E-mail Address Fax Telephone No. ( ) State Zip No changes since last report DHS use - ID No. for LEA
DESIGNATED ASBESTOS COORDINATOR (DAC) INFORMATION
Provide contact information including the date of birth for accurate identification in the database. Name of Asbestos Coordinator (first, middle, last, including suffixes - Jr., Sr., or III) Mailing Address City Work Telephone No. ( ) Email Address Fax Telephone No. ( ) State Date of Birth (mm/dd/yy) DHS use - ID No. for DAC Zip Cellular Telephone No. ( )
SUBMIT FORM Complete and send page 1 of this report to the Department by one of the following methods. Fax to (608) 266-9711 Mail to: Department of Health Services Asbestos and Lead Section, Room 137 P.O. Box 2659 Madison WI 53701-2659 Give a copy of the completed report, including page 2, to the school administrator or superintendent and maintain a completed copy with the school asbestos management plan. If you have questions or need assistance determining your compliance with the AHERA requirements, call the Asbestos and Lead Section at (608) 261-6876.
Signature of Designated Asbestos Coordinator
Date Signed (mm/dd/yy)
F-00047 (03/09) Page 2 of 2
Note: The checklist on this page is for your records only.
LEA's RESPONSIBILITIES UNDER AHERA Activities of persons who perform inspections, re-inspections, periodic surveillance, develop and update management plans, and develop and implement response actions are completed in accordance with 40 CFR Part 763, Subpart E. All custodial and maintenance employees are properly trained as required in 40 CFR Part 763, Subpart E and all other applicable federal and/or state regulations. (e.g., the Occupational Safety and Health Administration Asbestos in Construction Standard, Ch. COMM 32, Public Employees Safety and Health, and Ch. DHS 159, Asbestos Training, Certification and Course Accreditation for Asbestos Disturbance and Asbestos Management, NR 447, Control of Asbestos Emissions). All workers and building occupants, or their legal guardians, are informed at least once each school year about asbestos inspections, response actions, post-response action activities, including periodic re-inspections and surveillance activities, that are planned or in progress. All short-term workers (e.g., telephone repair workers, utility workers, or exterminators) who may come in contact with asbestos in a school building are provided information regarding the locations of asbestos-containing building materials and assumed asbestos-containing building materials. All warning labels are posted in accordance with section 763.95 of 40 CFR 763, Subpart E. All management plans are available for inspection, and notification of this availability has been provided in accordance with section 763.93 (g) of 40 CFR 763, Subpart E. The designated asbestos coordinator has received training as required by section 763.84 (g) (2) of 40 CFR 763, Subpart E. CHECKLIST FOR AHERA COMPLIANCE If you respond `No' to any of the following questions, take action to ensure compliance with AHERA. Yes No Has each school building that the LEA leases, owns or otherwise uses been inspected by a certified asbestos inspector to identify all locations of asbestos-containing building materials or assumed asbestos containing materials? Yes No Was any asbestos-containing building material or assumed asbestos-containing material found during the asbestos inspection? If no asbestos-containing materials were found, stop here. If yes, continue. Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No No Within the past 3 years, has a certified asbestos inspector conducted an asbestos inspection in each school building or a re-inspection of all known or assumed asbestos-containing material in each school building? For each inspection or re-inspection conducted, did the asbestos inspector provide the LEA with a written assessment of all friable asbestos-containing building material? Did a certified asbestos management planner review each three-year inspection report issued? Does the LEA have an up-to-date asbestos management plan for each school that covers each building under its authority? (Reminder - the first management plan developed must be on file with DHS.) Does the LEA follow an operations and maintenance program for managing friable asbestos-containing building material? ( Does not apply - no friable asbestos-containing building material is present.) Have all custodial and maintenance workers completed 2-hour asbestos awareness training within 60 days after hire, and annual refresher training, if they work in buildings with asbestos-containing building material? Do all custodial and maintenance workers complete 14-hour operations and maintenance training, including annual refresher training, if they might disturb asbestos-containing building material? Has the LEA verified the current certification status of all persons who perform asbestos abatement or response actions, asbestos inspections, asbestos management plans or asbestos project designs for a school? Does the LEA issue annual notice to workers and building occupants, or their legal guardians, of all inspections, reinspections, and activities being conducted to control asbestos exposure, including periodic surveillance and asbestos removal, that are planned or in progress? Does the LEA issue the required annual written notice to parents, teachers, and employee organizations that the management plan is available for their review? Does the LEA issue notice identifying the location of asbestos-containing building materials (assumed or known) to all short-term workers who might come into contact with asbestos in a school? Does the LEA conduct all periodic 6-month surveillances in each building under its authority? Does the LEA maintain in the administrative offices of both the school and the LEA, records of inspections and response actions for asbestos-containing building materials, including all the following: Descriptions of preventive measures and response actions taken for asbestos-containing building materials Sampling information Training information Periodic surveillance information Information on initial and additional cleaning performed Information on operations and maintenance activities, including maintenance activities disturbing friable asbestos Information on any fiber-release episodes Are warning labels attached to asbestos-containing building materials in routine maintenance areas (such as boiler rooms) at each school building?
Yes Yes Yes Yes
No No No No