DEPARTMENT OF LABOR & INDUSTRY BUREAU OF OCCUPATIONAL & INDUSTRIAL SAFETY LEAD TRAINING COURSE ACCREDITATION APPLICATION IMPORTANT: Page 1 of this application (fully completed) must be approved by the Department of Labor & Industry before a course can be accredited. Offering Lead training in Pennsylvania without Department accreditation will be grounds for disapproval of an application for accreditation. Please follow the directions on pages 1 and 2. PLEASE TYPE OR PRINT NEATLY IN INK Training Company Name Provider Contact Name Mailing Address City State Zip Code County Telephone Fax Email Training Manager Name Course Check the box next to each course you intend to offer. Accreditation Initial Initial Renewal Refresher Refresher Renewal Abatement Worker Inspector Project Designer Risk Assessor Supervisor Reciprocity Has the U.S. Environmental Protection Agency (EPA) accredited any of these courses? Yes No If 223Yes224, supply name(s) of course(s): Has another state accredited any of these courses? Yes No If 223Yes224, which state? Supply name(s) of course(s): Instructor(s) 1. Name Telephone Mailing Address City State Zip Code Training Course Location Subject Areas Taught Experience 2. Name Telephone Mailing Address City State Zip Code Training Course Location Subject Areas Taught Experience Signature By signing this document, I certify that the above information is correct and that all accredited courses will comply with current and future statutory and regulatory requirements. Training Manager Name (Printed or Typed): Training Manager Name (Signed): Date Signed: FOR L&I USE ONLY Check #: Amount:$ Bates #: LIBI-603L REV 03-18 (Page 1 of 2) American LegalNet, Inc. www.FormsWorkFlow.com Filing Requirements Under the authority of Act 44 of 1995, the Pennsylvania Department of Labor & Industry established its Lead Occupations and Accreditation Program. This statute authorizes the department to accredit all lead training courses offered in Pennsylvania. In order for lead abatement training courses to be accredited, all of the following must be provided: B. Payment of the required fees via check or money order made payable to Commonwealth of Pennsylvania. For an up-to-date listing of fees, please see the Fee Schedule listed on our for a copy of the Fee Schedule by email CALBOIS@pa.gov, by telephone at 717-772-3396 or by fax at 717-705-0196. C. For , the following must be submitted: 1. Copies of supporting documentation for each course previously accredited by the EPA or another state. 2. Description of the facilities and equipment to be used for lecture and hands-on training. 3. The entire content of each course for which you are seeking Pennsylvania accreditation. The following must be included: a) The curriculum, including: I. Length of training (in days) II. Topics covered III. Amount and type of hands-on training IV. Length, format and passing score for examination(s) b) Copies of all course materials including course agenda, student manuals, instructor handbooks, hand-outs and examinations. c) Description of how the examination was developed. d) Description of the activities and procedures that will be used for conducting the assessment of hands-on skills. course. 4. A copy of each Instructor222s resume. 5. Copy of the Quality Control Plan, which will show the procedures for periodic revision of for the training manager222s annual review of the principal instructor(s) competency.D. For renewals without changes, the following must be submitted: 1. A cover letter, on company letterhead, that indicates the previously submitted course, curriculum and documents have not changed. Mail the completed application, your payment and any additional documentation to: PA Department of Labor & Industry Course Approval The Department of Labor & Industry will act on applications that are administratively complete approved training course. General Information 1. Failure to submit all applicable information will result in denial of your application. 2. Should an application be denied, any course fees remitted with the application will not be returned to the applicant. 3. Training course providers must permit employees or authorized representatives of the Department of Labor & Industry to attend or monitor any training course without charge, as part of our evaluation. We reserve the right to do this without prior notice to training providers. 4. Accreditation of a course may be suspended and/or revoked if our on-site visit indicates that a course is not in compliance with federal and state requirements. CALBOIS@pa.gov. 651 Boas Street, Room 1623 | Harrisburg, PA 17121 | 717.772.3396 | Fax 717.705.0196 | CALBOIS@pa.gov | www.dli.pa.gov Auxiliary aids and services are available upon request to individuals with disabilities.002 Equal Opportunity Employer/Program002 LIBI-603L REV 03-18 (Page 2 of 2) American LegalNet, Inc. www.FormsWorkFlow.com