New Jersey Department of Health

Consumer, Environmental and Occupational Health Service

P. O. Box 372

Trenton, NJ 08625-0372

Required Information for New Jersey Certification of Asbestos Training Course

Asbestos Training Course Proposal Checklist

Please provide all information requested in this checklist along with your completed application and return it to the above address with all required attachments.

Name of Training Agency

Date

Course Type (Check no more than one initial and corresponding refresher):

Worker-Initial	Supervisor-Initial

Worker-Refresher	Supervisor-Refresher
To assure your application is complete and to expedite the review process, the following information must be submitted as required in N.J.A.C. 8:60-6:
8:60-6.3(a)1.

Complete "Asbestos Training Agency Certification – Initial Application"
8:60-6.3(a)2.

Brief description of course location including dimensions:
Projected course fees:	$____________________
8:60-6.3(a)3.

Brief description of public outreach and publicity efforts to recruit students:
8:60-6.3(a)4.

Must provide a detailed outline of course curricula as set forth at N.J.A.C. 8:60-6 which details the schedule for each day of the course. NJDOH model outlines for each discipline are available online at: www.state.nj.us/health/iep/asb_outlines.shtml. The amount of time allotted for each topic and a list of instructors for each topic must also be included with the outline.
8:60-6.3(a)5.

Must attach a description of the interactive/participatory teaching methods as defined at N.J.A.C. 8:60-2 which will be employed to present each topic. As a reminder, lecture is not considered an interactive/participatory teaching method.
8:60-6.3(a)6.

Must attach a copy of all written materials to be distributed as part of the training course.
8:60-6.3(a)7.

Must include evidence that your agency has employed or contracted to employ a minimum of three instructors, either on a full time or temporary basis, to satisfy the education, experience qualifications criteria as set forth at N.J.A.C. 8:60-6.5. An “Application for Approval as a New Jersey Asbestos Course Instructor” must be completed and submitted for each instructor. Resumes describing special training and education and/or prior experience shall be submitted as documentation of compliance with the instructor criteria. All resumes must include the length of time which the individual has held jobs, certifications, etc.
8:60-6.3(a)8.

List the types, brand name and quantities of respirators to be used to demonstrate fit test or flow test:
Type
Brand Name
Quantity
8:60-6.3(a)9.

List a description of the type and quantity of protective clothing to be used during practice exercises and demonstrations (use an additional sheet of paper if necessary):
Description
Quantity
Description
Quantity
8:60-6.3(a)10.

List a description and quantities of the materials to be used for hands-on practice exercises and demonstrations including, but not limited to, hand tools, ladders, scaffolding, plastic sheeting and other barrier construction supplies, air filtration units, water spray devices, decontamination facilities, simulated asbestos material and, where appropriate, Material Safety Data Sheets (use an additional sheet of paper if necessary):
Description
Quantity
Description
Quantity
8:60-6.3(a)11.

Attach a statement explaining any restrictions on attendance, such as English only or other language to be used.
8:60-6.3(a)12.

All training course materials, examinations and related course literature for non-English courses must be translated into the language of the course. A copy of the translated materials with written assurance that the translation is accurate and valid must be included. Note: Only the worker course may be taught in a foreign language.
8:60-6.3(a)13.

What is your instructor-to-student ratio for hands-on training?

(Note: Minimum ratio shall be no greater than 10 students for one instructor.): ____________________
8:60-6.3(a)14.

Must provide evidence that a no-smoking policy shall be established, maintained and enforced during all aspects of the training.
8:60-6.3(a)15.

If applicable, attach a copy of valid training agency certification previously issued by the NJDOH pursuant to N.J.A.C. 8:60.
8:60-6.3(a)16.

Attach a copy of the written examination(s) to be administered to the trainees by your training agency. Also include the performance procedures used to validate your examination.
All materials submitted as part of the application must be typewritten or machine printed. The applicant shall be required to successfully pass a pre-commencement inspection of the training facility(ies) conducted by representatives of the Department. The applicant shall notify the Department immediately in writing of any change(s) in the application information occurring either prior to or after the issuance of certification.
Name of Person Completing This Form (Print):

Title

Signature	Date

ASBESTOS TRAINING COURSE PROPOSAL CHECKLIST

(Continued)

EHS-39

JUL 12	Page 3 of 3 Pages.

JUL 12	Page 1 of 3 Pages.

EHS-39, Asbestos Training Course Proposal Checklist

EHS-39, EHS, asbestos, training, course, proposal, checklist, indoor environments program,

ewhite

2011-04-13

NJDOH