Free Lead Abatement Worker General Supervision Qualification Affidavit, DPH 44015 - Wisconsin

DEPARTMENT OF HEALTH AND FAMILY SERVICES Division of Public Health DPH 44015 (03/02)

STATE OF WISCONSIN Bureau of Occupational Health HFS 163, Wis. Adm. Code

LEAD ABATEMENT WORKER GENERAL SUPERVISION QUALIFICATION AFFIDAVIT
Read the following information before completing form. Give a copy to the lead abatement worker and retain an original copy of this Qualification Affidavit on file for company records.

Lead Abatement Worker - General Supervision Provisions: General supervision is only allowed on an site when enclosure or encapsulation of lead-based painted components are the only types of abatement conducted and where the lead-based paint or lead-based paint components will not be removed. General supervision is also only allowed after the lead abatement worker has demonstrated appropriate independent knowledge and skills in the work to be conducted. Minimum Standards for General Supervision: Under the requirements of general supervision, a certified lead abatement supervisor must make a visit to the work site before work begins to ensure proper work site set-up and compliance with the occupant protection plan. The certified lead abatement supervisor must also make daily visits to verify compliance with work practice standards, daily cleanup and disposal of debris. Requirement for Direct On-Site Supervision: When abatement is performed by removing lead-based paint from components or by removing lead-based painted components, a certified lead abatement supervisor must be on-site at all times while work is performed, including work site set-up, all lead abatement activities, work site clean-up and disposal of debris. Lead Abatement Worker (Print Name) WI Lead Certification No.

Check activities below for which the lead abatement worker has demonstrated independent knowledge and skills in following proper protocols and regulations. Activities Work-site preparation Understands occupant protection Enclosure of a component Encapsulation of a component Daily clean-up Proper disposal Final clean-up I certify that the lead abatement worker named above has been personally supervised and observed by me, and consistently understands and demonstrates compliance with pertinent regulations and protocols when performing abatement activities relating to enclosure and encapsulation. I further understand that abatement activities performed under general supervision must be limited to enclosure or encapsulation. Signature ­ Lead Contract Supervisor Lead Company Name WI Lead Certification No. WI Lead Certification No. Date Signed

For more information, contact the Asbestos and Lead Section by calling (608) 261-6876, faxing (608) 266-9711 or at www.dhfs.state.wi.us/dph_boh/asbestos lead Mailing Address Department of Health and Family Services Asbestos and Lead Section, Rm 137 P.O. Box 2659 Madison WI 53701-2659