Application For Lead Based Paint Training Course Provider Approval {50747}

APPLICATION FOR LEAD-BASED PAINT TRAINING COURSE PROVIDER APPROVAL State Form 50747 (R6 / 4-11) Approved by State Board of Accounts, 2011 APPLICATION TYPE INDIANA STATE DEPARTMENT OF HEALTH INSTRUCTIONS: 1. This form must be used to apply for training course provider approval pursuant to 410 IAC 32. 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): Initial approval of course Re-approval of course 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 6. E-mail address: Title 5. Telephone number: Fax number: 7. Name of Training Course: PART C: CURRENT TRAINING COURSE APPROVAL STATUS 8. 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. Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com INDIANA STATE DEPARTMENT OF HEALTH LEAD AND HEALTHY HOMES PROGRAM State Form 50747 (R6 / 4-11) Application for Lead-Based Paint Training Course Provider Approval 4/11 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 410 IAC 32-3-2(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 410 IAC 32-1-63. 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 410 IAC 32-3-8), 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 410 IAC 32. 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 410 IAC 32 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. Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com INDIANA STATE DEPARTMENT OF HEALTH LEAD AND HEALTHY HOMES PROGRAM State Form 50747 (R6 / 4-11) Application for Lead-Based Paint Training Course Provider Approval 4/11 PART F: APPLICATION FEES APPLICATION FEE: (Per 410 IAC 32-3-12(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 410 IAC 32-2-9(c)