New Jersey Department of Health and Senior Services

Consumer and Environmental Health Services

P. O. Box 372

Trenton, NJ 08625-0372	FACILITY INSPECTION WORKSHEET - LEAD

Name of Training Agency

Training Agency Number

Date of Inspection

Street Address

Courses Agency Applied/Approved for (check all that apply):
Housing and Public Buildings

Worker

Supervisor

Inspector/Risk Assessor

Planner/Project Designer	Commercial Buildings and Superstructures

Worker

Supervisor
City

State

Zip Code

Telephone Number

( )	Fax Number

( )
Type of Inspection
Pre-Certification	Renovated Facility

Add New Facility	Other (Specify):
INSTRUCTIONS: Check ALL the following areas and mark the appropriate box.

If necessary, explain "NO" answers on a continuation sheet. Precede each explanation with the item number.

For Inspector/Risk Assessor discipline, complete Sections 1-4 and 11.

For Worker, Supervisor and Planner/Project Designer disciplines, complete Sections 1-3 and 5-11.
Yes	No	N/A	Description	Yes	No	N/A	Description
1. Training Information Record (EHS-9)
4. Sampling Items (Cont’d)
a. Secure (locked) location
f. Air pump (5)
b. Account log of forms
g. Air sampling cassettes (case)
c. Other:
h. Surface area for sampling
2. Classroom
5. Equipment, Supplies
a. Adequate size for (no.) ______ trainees
a. Pry bars (5 varied sizes)
b. Adequate lighting
b. HEPA vacuum (1)
c. Writing surface (desks, tables, etc.)
c. Scrapers (25)
d. Adequate seating (see number in 2.a.)
d. 6 mil waste bags, solvent resistant (1 case)
e. Adequate ventilation
e. Disposable clothing (1 case)
f. Comfortable temperature
f. Air filtration differential unit (1)
g. Acceptable background noise
g. Duct tape (1 case)
h. Other:
h. Ladders (2)
3. Audio Visual
i. Scaffolds (1)
a. Up-to-date/relevant videos/DVDs
j. Solvent strippers (2 types)
b. Working equipment
k. Ground fault circuit interrupters (3)
c. Legible/understandable overhead slides
l. Warning signs (5)
4. Sampling Items
m. 6 ml poly sheeting (1 case)
a. Direct reading XRF and/or spectrum analyzer (1)
n. Encapsulants (paint, cloth, barrier)
b. Swab analysis kit (5)
o. Caulk gun and caulk (2)
c. Sample containers (20)
p. Heat gun (1)
d. Wipes (1 container)
q. Screw gun (2)
e. Vacuum sampler & collection medium (5)
r. Trisodium phosphate/other cleaning products
6. Hands-On Training Area
6. Hands-On Training Area (Con’d)
a. Adequate size (see number in 2.a.)
k. Site security items (caution tape, etc.)
b. Adequate lighting
7. Safety Items for Hands-On
c. Adequate ventilation
a. Material Safety Data Sheets (as applicable)
d. Comfortable temperature
b. Emergency numbers
e. Decon system (per applicable regulations)
c. Eye wash station (1)
f. Adequate airlock widths
d. Fire extinguisher (1)
g. Three-flap airlock system
e. Eye protection (10)
h. Air differential opening
f. Hard hats (10)
i. Critical barriers (per applicable regulations)
g. Solvent resistant gloves (1 case)
j. Removal substrate (must adequately represent conditions of actual removal according to discipline approved for)
8.	Total sq. footage of simulated surfacing lead material:	_______
9. Miscellaneous Hands-On Items
10. Brands and Quantities of Respirators Used
Brand 1:	Brand 2:
Amounts	Number (Quantity) of Respirators by Type
a. Type “C” Supplied Air	b. PAPR	c. Full Face	d. Half Face	e. Other:

________
Small	Medium	Large	Small	Medium	Large
Amount Brand 1
Amount Brand 2
11. Comments

Inspection Results

Satisfactory Unsatisfactory Conditionally Satisfactory (see comments)	Maximum No. of Trainees
Initial

Course	Refresher

Course
Name of Inspector (Print)

Signature of Inspector	Date

Name of Training Agency Representative (Print)

Title

Signature of Training Agency Representative	Date

FACILITY INSPECTION WORKSHEET – LEAD

(Continued)

EHS-10

MAY 12	Page 2 of 2 Pages.

MAY 12	Page 1 of 2 Pages.

EHS-10, Facility Inspection Worksheet - Lead

EHS-10, consumer and environmental helth services, facility inspection, worksheet, lead, training agency

Elaine White

2002-05-14

ewhite

NJDHSS