APPLICATION FOR ASBESTOS TRAINING COURSE PROVIDER APPROVAL State Form 48741 (R / 2-06) Approved by State Board of Accounts, 2006 INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT NOTE: IDEM – Office of Air Quality Asbestos/Lead Program 100 N. Senate Avenue Indianapolis, IN 46204-2251 Phone: (317) 232-8219 or 1-888-574-8150 (Nationwide) http://www.in.gov/idem/permits/air/ This form must be used to apply for training course provider approval pursuant to 326 IAC 18. 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. APPLICATION TYPE 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 "IDEM Asbestos Trust Fund" by mail to: Type of application (check one): First-Time Approval Cashier – Mail Code 50-10C Indiana Department of Environmental Management 100 North Senate Avenue Indianapolis, Indiana 46204-2251 Re-approval PART A: GENERAL INFORMATION Type of Course (check one): Initial Inspector Refresher (not applicable to Indiana Rules Awareness course) Management Planner Project Designer Name of Course (check one): Project Supervisor/Contractor Worker PART B: TRAINING COURSE PROVIDER INFORMATION 1. Training Course Provider Name: 2. Mailing Address: Street City State ZIP code 3. Training Location Address: Street City State ZIP code 4. Primary Contact Person - Name and Title: First Last 5. Phone #: ( ) Middle Initial Title - 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 6820-120000-421100 * If yes, attach to this application written evidence of such approval Page 1 of 3 American LegalNet, Inc. www.FormsWorkflow.com INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT OFFICE OF AIR QUALITY State Form 48741 (R / 2-06) Application for Asbestos Training Course Provider Approval PART D: TRAINING MATERIALS TO BE SUBMITTED WITH FIRST-TIME APPLICATION FOR INITIAL AND REFRESHER TRAINING COURSES ► Any training course provider seeking first-time approval of an approved initial or refresher training course must provide the following: 1) 2) A written copy of the course curriculum. A letter that clearly indicates how the course meets the applicable requirements of 326 IAC 18-2-3 through 18-2-5, including the following information: a. b. c. d. 3) 4) 5) 6) A copy of all course materials (student manuals, instructor notebooks, handouts, etc.). 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 (all course instructors must meet the qualifications as listed in 326 IAC 18-2-10.1), including academic credentials and field experience in asbestos abatement management. 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. 7) Length of training in days. Amount and type of hands-on training. Examinations (length, format, and passing score). Topics covered in the course. Name of accredited person. Discipline of the training course completed. Dates of the training course. Date of the exam. An expiration date not to exceed one (1) year 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 asbestos accreditation under TSCA Title II. A statement that the training course meets requirements as outlined by the State of Indiana under 326 IAC 18-2. A detailed statement of how the training course provider ensures that all requirements for training students be met in the event that: a. b. The instructor does not speak a language understood by all students. The course materials are not in a language understood by all students. PART E: TRAINING MATERIALS TO BE SUBMITTED WITH REAPPROVAL APPLICATION FOR INITIAL AND REFRESHER COURSES ► 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 18 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. PART F: APPLICATION FEES FIRST-TIME APPROVAL: Upon first-time application for initial or refresher lead training course approval, an asbestos training course provider shall pay an application fee of one thousand dollars ($1000) per course. REAPPROVAL: Upon application for initial or refresher asbestos training course re-approval, a training course provider shall pay an annual application fee of five hundred dollars ($500) per course. TOTAL AMOUNT ENCLOSED $ ► Pursuant to 326 IAC 18, 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. 6820-120000-421100 Page 2 of 3 American LegalNet, Inc. www.FormsWorkflow.com INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT OFFICE OF AIR QUALITY State Form 48741 (R / 2-06) Application for Asbestos Training Course Provider Approval PART G: NOTES ► IMPORTANT • 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 18-2. 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 phone number, or primary contact person. • No person shall make representation as conducting an Indiana-approved initial training course or approved refresher training course for the purpose of licensing persons under 326 IAC 18-1 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 18. PART H: SIGNATURE I hereby certify that there are no misrepresentations in or falsifications of information submitted in this application or addenda. I understand that should investigations disclose any falsifications of information submitted in this application or any addenda, my letter of approval may be revoked. I further certify that this course will be conducted in the fullest adherence and compliance to all federal, state, and local regulations, including, but not limited to, the United States Environmental Protection Agency’s revised asbestos model accreditation plan and the state of Indiana’s 326 IAC 18. I understand that failure to comply with requirements as outlined within federal, state, or local asbestos-related regulations may result in civil and/or criminal penalties. SIGNATURE OF PRIMARY CONTACT: ___________________________________________ 6820-120000-421100 DATE SIGNED: / / Page 3 of 3 American LegalNet, Inc. www.FormsWorkflow.com