Free 50747.pdf - Indiana

APPLICATION FOR LEAD-BASED PAINT TRAINING COURSE PROVIDER APPROVAL
State Form 50747 (R4 / 2-08) Approved by State Board of Accounts, 2008

INDIANA STATE DEPARTMENT OF HEALTH INSTRUCTIONS: 1.

Reset Form

INDIANA STATE DEPARTMENT OF HEALTH Lead and Healthy Homes Program 2 N Meridian St, 5 J Indianapolis, IN 46204 Phone: (317) 233-1250

http://www.in.gov/isdh/programs/lead/
This form must be used to apply for training course provider approval pursuant to 326 IAC 23. If accessing this form on-line, you may print the blank form and fill it out by hand; or you may fill it in on-line, and then save it to your computer and print a hard copy for submission with original signatures. Submit one application form for each course for which you are seeking approval. Please type or print in ink. Return this form, required addenda, and check or money order made payable to "ISDH Lead and Healthy Homes Program" by mail to: Cashier's Office Indiana State Department of Health PO Box 7236 Indianapolis, Indiana 46207

2. 3. 4.

APPLICATION TYPE

Type of application (check one): First Time Re-approval

PART A: GENERAL INFORMATION
Type of course (check one): Initial Inspector Name of course (check one): Clearance Examiner 2-Hour Indiana Rules Awareness Refresher (not applicable to Indiana Rules Awareness course) Project Designer Project Supervisor Worker

Risk Assessor

PART B: TRAINING COURSE PROVIDER INFORMATION

1. Training Course Provider Name: 2. Mailing address: Street 3. Training location address: Street 4. Primary contact person name and title: Last First ( ) City State ZIP code

City

State

ZIP code

Middle Initial

Title

5. Telephone number:

6. Name of Training Course:

PART C: CURRENT TRAINING COURSE APPROVAL STATUS 7. Does this course currently have full or contingent approval by the U.S. Environmental Protection Agency or by a state under an accreditation program approved by the U.S. Environmental Protection Agency? YES* NO
* If yes, please submit written evidence of such approval.

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INDIANA STATE DEPARTMENT OF HEALTH LEAD AND HEALTHY HOMES PROGRAM State Form 50747 (R4 / 2-08)

Application for Lead-Based Paint Training Course Provider Approval 2/08

PART D: TRAINING MATERIALS TO BE SUBMITTED WITH FIRST-TIME APPLICATION Any training course provider seeking first-time approval of an approved initial or refresher training course or 2-hour Indiana Rules Awareness course must provide the following (items marked with an asterisk (*) do not apply to Indiana Rules Awareness course):

1) 2)

A written copy of the course curriculum. A letter that clearly indicates how the course meets the applicable requirements of 326 IAC 23-3-2(1)(e), including the following information:
a. b. c. d. e. f. g. h. Length of training in days. A description of the facilities and equipment to be used for lecture and hands-on training. *Amount and type of hands-on training. *Description of the examinations (length, format, and passing score). *A description of the activities and procedures that will be used for conducting the assessment of hands-on skills for each course. Topics covered in the course. *A copy of the quality control plan as defined in 326 IAC 23-1-56. A copy of certificates of training.

3) 4) 5) 6) 7)

*A copy of the training course test blueprint for each course. A copy of all course materials (student manuals, instructor notebooks, handouts, etc.). If course materials are based upon the U.S. EPA-recommended model training materials, the training course manager shall include a statement certifying that the recommended version will be used. *A detailed statement about the development of the examinations used in the course. Provide a copy of the course examinations to be used. The names and qualifications of course instructors, including guest instructors (all course instructors must meet the qualifications as listed in 326 IAC 23-3-8), and including academic credentials and field experience. A description and an example of numbered certificates issued to students who complete the course and pass the examination with the following:
a. b. c. d. e. f. g. h. Name and address of accredited person. Discipline of the training course completed. Dates of the training course. *Date of the exam. An expiration date not to exceed thirty-six (36) months after the date upon which the person successfully completed the course and passed the examination. The name, address, and telephone number of the training provider who issued the certificate. A statement that the person receiving the certificate has completed the requisite training for lead-based paint accreditation. A statement that the training course meets requirements as outlined by the State of Indiana under 326 IAC 23. The instructor does not speak a language understood by all students. The course materials are not in a language understood by all students.

8)

A detailed statement of how the training course provider ensures that all requirements for training students be met in the event that:
a. b.

PART E: TRAINING MATERIALS TO BE SUBMITTED WITH REAPPROVAL APPLICATION Any training course provider seeking reapproval of an approved initial or refresher training course must provide the following additional information:

1) A description of any changes to the training facility, equipment, or course materials or curriculum since its last application was
approved that adversely affects the students' ability to learn.

2) A statement signed by the program manager stating that the training course provider complies with all requirements of 326 IAC
23 and that all record keeping and reporting requirements shall be followed.

3) Names and qualifications of instructors, including guest instructors, and academic credentials and field experience.

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INDIANA STATE DEPARTMENT OF HEALTH LEAD AND HEALTHY HOMES PROGRAM State Form 50747 (R4 / 2-08)

Application for Lead-Based Paint Training Course Provider Approval 2/08

PART F: APPLICATION FEES

APPLICATION FEE:
(Per 326 IAC 23-3-12(e) local, city, county, and state governments, and nonprofit organizations are exempt from application fees.)

Upon application for initial or refresher lead training course approval or reapproval, a training course provider shall pay an application fee of one thousand dollars ($1000) per course. Upon application for the 2-hour Indiana Rules Awareness course approval or reapproval, a training course provider shall pay an application fee of five hundred dollars ($500).

TOTAL AMOUNT ENCLOSED

$

Pursuant to 326 IAC 23-2-8(c), the nonrefundable application fee is not: - Transferable from one (1) application to another, - Transferable from one (1) training course provider to another, - Transferable to any other type of license issued by the department, unless requested by the applicant and approved by the department within three (3) days of submittal to the department or prior to application processing by the department, whichever is earlier.

PART G: CERTIFICATION AND SIGNATURE
I hereby certify that there are no misrepresentations in or falsifications of information submitted in this application. I understand that should investigations disclose any falsifications of information submitted in this application, my lead-based paint training course provider approval may be revoked. I have read Indiana's lead-based paint rule 326 IAC 23, and I understand the requirements of this rule. I understand that failure to comply with requirements as outlined within federal, state, or local lead-based paint related regulations may result in civil and/or criminal penalties.

SIGNATURE OF PRIMARY CONTACT: __________________________________

DATE SIGNED:

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PART H: NOTES
IMPORTANT

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Allow a minimum of eight (8) weeks for processing of a complete training course provider approval application. Make sure you have completed all appropriate sections of this application and have included all required addenda. Sign and date the application and return it to the CASHIER address shown on page one (1). Applications will be returned which are incomplete or contain errors in response to any questions on the form and will result in a delay in processing and issuance of your letter of training course approval. All information requested on this application is mandatory for the administration and processing of your training course provider application pursuant to 326 IAC 23. All data received will be regarded as a public record subject to disclosure in accordance with IC 5-14-3 and 326 IAC 17-1-4. A training course provider must notify the Department in writing within thirty (30) days whenever there is a significant change in the course curriculum, instructional staff, training provider mailing address, training provider telephone number, or primary contact person. No person shall make representation as conducting an Indiana-approved initial training course or approved refresher training course or Indiana Rules Awareness course for the purpose of licensing persons under 326 IAC 23-2 without prior written approval from the department. In any oral or written statement that indicates Indiana's approval of a training course, course providers must clearly indicate that the course is only approved for purposes of licensing under 326 IAC 23.

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