Document baLw8XDwoYoB49kjk1qjxX5oy
Lead-Related Construction Interim Certification Application Instructions
California Department of Health Services, Childhood Lead Poisoning Prevention Branch, Lead Accreditation & Certification Unit (February 1995)________________________________
General Information:
The Department of Health Services, Childhood Lead Poisoning Prevention Branch accepts applications for interim certification for the following 5 lead;related construction disciplines:
Inspector/Assessor Project Designer
Supervisor
Worker
Project Monitor
All certificates the Department grants are "interim" until a state certification exam is ready (in about 2
years).
Eligibility for Interim Certification:
The chart on page 3 shows the eligibility requirements for each type of interim certificate. You
must meet all the appropriate eligibility requirements for all the certificate(s) you request before you apply. Be sure to include all the necessary documents with
your application.
DO NOT rely on information provided by your training provider to determine your eligibility. If you have questions or need assistance determining your eligibility contact our Hotline.
Applying for Interim Certification:
To apply for interim certification, you will need to:
Complete (in ink) and sign the attached application form (DHS form 8488). Be sure to complete both sides of the form. Be sure to fill in a photo identification number such as from your driver's license, passport, military ID card, INS resident alien card, etc.
Send documentation that you have satisfied the training, education, and experience requirements. (Sample documents are included in this packet.) Do not ask employers, schools, or training providers to send information directly to the Department. All information must accompany your application.
Send 2 recent passport photographs of yourself (nsi Polaroid, photo copies, cropped family pictures, etc.). Write your name on the back of your photos. Do not staple or paste photos to your application.
O Include a fee of $75.00 for each interim certificate you request. IMPORTANT: All fees are non-refundable.
It is important that you read and follow all application instructions. Incomplete or incorrect applications will not be processed.
Submitting Your Application:
We strongly recommend that you keep a copy of your completed application for your own records. It will be useful when you renew your interim certificate.
Mail all your application materials together to the address below. If you are a company or individual submitting applications for several people, please make sure each person's application is signed by the applicants and the materials are securely clipped together. Mail all applications to:
Department of Health Services Childhood Lead Poisoning Prevention Branch
Lead Accreditation and Certification Unit 5801 Christie Ave., Suite 600, Box C Emeryville, CA 94608
HOTLINE: (510) 450-2447
Please do not address your application to DHS staff members. This will slow your application processing. If you plan to deliver your application by hand, you may do so between the hours of 9:00 am and 5:00 pm. Hand-delivered applications must be placed in a sealed envelope with the above address on the outside.
Lead-Related Construction Interim Certification, Application Instructions
i
N2163
California Department of Health Services
Application Instructions (February 1995)
Your Lead-Related Construction Training
Before you apply...
When you apply...
You must take all the appropriate lead-related construction training. (See the chart on page 3.) You have 1 year after completing your training to apply to us. If you wait longer than 1 year, you must take continuing education before applying. (Call our Hotline to find out which kind of continuing education you need.)
All training completed after Nov. 1, 1994; must be taken from a DHS-accredited training provider. If you take training after Nov. 1, 1994, from a nonaccredited training provider your application will be denied. Call our Hotline for a list of DHS-accredited training providers.
You must submit a Course Completion Form (DHS Form 8493). Your DHS-accredited training provider will give you this.
If you took training before Nov. 1, 1994 you must submit proof of training. See page 5 for a sample training letter. If you submit a letter, it must include all the information shown in [BOLD] in the sample training letter. If any of this information is missing, your application will be delayed.
Your Lead-Related Construction or Other Applicable Experience
Before you apply...
When you apply...
The Inspector/Assessor, Supervisor, Project Monitor and Project Designer interim certificates have experience requirements. (See the chart on page 3.) Please note that your experience must be in certain kinds of work. Use the calculation table on page 4 to see if you have enough experience to meet the requirements.
If you are a California State Licensed Contractor, your license may qualify as part of your experience. (See the chart on page 4.)
Your proof of experience can be submitted on a form or in a letter (see pages 5 and 6 for examples). To speed your application processing, we recommend you use the sample experience form. If you use a letter, it must include all the information shown in [BOLD] in the sample experience letter. If any of this information is missing, your application will be delayed.
Your Postsecondary Education
Before you apply...
When you apply...
The Inspector/Assessor, Project Monitor and Project Designer interim certificates have education
requirements. If you do not meet these education requirements, you may be able to substitute extra experience for your education. (See the chart on page 3.)
You can submit a copy of your diploma or school transcripts. If you are substituting experience for your education, this should be indicated on your sample experience form or in your experience letter.
We encourage you to review the eligibility requirements on the next page and to apply if you feel you are eligible. If you have questions or need assistance determining your eligibility contact our Hotline.
2 Lead-Related Construction Interim Certification, Application Instructions 49 TOC 002047
Application Instructions (February 1995)
California Department of Health Services
Eligibility Requirements
Use the chart below to look up the training, experience and education eligibility requirements for the interim certificate(s) you are seeking. You are eligible for interim certification if you meet all the listed requirements.
A. Training Requirement
B. Experience Requirement
C. Education Requirement
Successfully complete a 40 contact Have one year of experience as Have completed at least two years
o hour DHS-approved lead-related V) construction Inspection and
a lead-related construction Supervisor
of postsecondary education in biological, chemical, or physical
0) Assessment course
sciences, or a related field.
ifi Vi
OR
OR
OR
ow
Have completed at least 32 contact Have one year of experience in hours of lead-related construction an occupation conducting
4oa>
inspection and assessment training inspections"and assessing health,
before Nov. 1, 1994
safety, or environmental hazards.
cifi
Posses a high school diploma or its equivalent and substitute additional related experience (see Box B) for post secondary education on a year-for-year basis.
Successfully complete a 40 contact Have one year of experience as
hour DHS-approved lead-related
a lead-related construction Worker
construction Supervision/ Project
o Monitoring course
ifi
> OR
OR
a> Have completed at least 32 contact Have two years of experience in
3 hours of lead-related construction the building trades conducting
(0 Supervision/Project Monitoring
health, safety, or environmental
training before Nov. 1, 1994
hazard control
NONE
Successfully complete a 40 contact Have one year of experience as Have completed at least two years
hour DHS-approved lead-related
a lead-related construction
of postsecondary education in
o construction Supervision/Project
Supervisor
biological, chemical, or physical
c Monitoring course
o 2
OR
sciences, or a related field. OR OR
' 4"* o
o
Have completed at least 32 contact Have one year of experience in hours of lead-related construction an occupation conducting and/or
Posses a high school diploma or its equivalent and substitute additional
0 Supervision/Project Monitoring
monitoring health, safety, or
related experience (see Box B) for
a. training before Nov. 1,1994
environmental hazard reduction
post secondary education
projects
on a year-for-year basis.
Successfully complete a 56 contact Have one year of experience as Have completed at least two years
hour DHS-approved lead-related
a lead-related construction
of postsecondary education in
o construction Project Design course Supervisor
biological, chemical, or physical
O) sciences, or a related field.
0)
m
OR
o Have completed at least 48 contact Have one year of experience in
OR Posses a high school diploma or its
hours of lead-related construction
o
nx*
Project Design training before
' W November 1, 1994 &
an occupation conducting or designing health, safety, or environmental hazard reduction projects
equivalent and substitute additional related experience (see Box B) for post secondary education on a year-for-year basis.
Successfully complete a 32 contact hour DHS-approved lead-related % construction Work course
O OR 5 Have completed at least 24 contact
hours of lead-related construction Work training before Nov. 1, 1994
NONE
NONE
You may not combine experience from these two options to satisfy their experience requirement.
Lead-Related Construction Interim Certification, Application Instructions
49 TOC 002048
3
California Department of Health Services
Application Instructions (February 1995)
State of California Licensed Contractors
The experience you have which qualifies you to be a licensed contractor in California may also satisfy your experience requirement for interim certification. If you have been a State of California Licensed Contractor for
at least 1 year, in any of the categories listed below, you may have satisfied the experience eligibility requirement for interim certification. Be sure to include your State of California Contractor's License number
on your experience form or letter. This will help DHS to process your application more quickly.
General Engineering Contractor........................ General Building Contractor............................... Boiler, Hot Water Heating and Steam Fitting............ .......................................... Building Moving, Demolition............................... Earthwork and Paving........................................ Flooring and Floor Covering.............................. General Manufactured Housing......................... Glazing............................................................... Parking and Highway Improvement..................
A B
C-4 C-21 C-12 C-15 C-47 C-17 C-32
Painting and Decorating......................... Pipeline.................................................. Plumbing................................................ Roofing.......................................... ......... Sheet Metal............................................ Sand & Water Blasting........................... Clean-up................................................. Asbestos........ ........................................ Hazardous Substance Removal............
C-33 C-34 C-35 C-39 C-43 C-61 / D-38 C-61/D-63 ASB HAZ
Calculating Your Experience
Use the following steps to calculate the amount of applicable experience you have.
1. Find the dates you started and stopped working for an employer.
Sample Information
Lead-BGone, Inc start: 10/1/&& . end: / 2/f/<30 .
2. Count the number of months that you worked for that
A
employer and write it in Box A................................................. >
120.0 months
3. Estimate the percentage of time that you did lead-related B construction or other applicable activities for that employer
and write it in Box B.-------------------------------------------------------- >- X
00.5 (50%)
Your Information
start: end: A
B
X
4. Multiply the total number of months worked (Box A) by the C estimated percentage of time you did lead-related construction or other applicable activities (Box B). Write the result in Box C.................. ......................................... >-
-f-
5. Divide the number of months you did lead-related construction or other applicable activities (Box C) by 12 to calculate your experience in years.
Write the result in Box D.......................................................... ->
D
60.0 months 12.0
5.0 years
C
-t- 12.0 D
Repeat this calculation for each of your applicable employment experiences. Add together the results (Box D)
of all your experience calculations. The grand total of aU your lead-related construction or other applicable employment experiences must equal or exceed the experience requirements shown in the chart on page 3.
4 Lead-Related Construction Interim Certification, Application Instructions 49 TOC 002049
Lead-Related Construction Interim Certification, Application Instructions
Proof of Training Sample Letter
Here is a sample training verification letter for a course taken before Nov. 1,1994.
Proof of Experience Sample L
Here is a sample letter of employment verificati supplied by an employer.
49 TOC 002050
Be sure to include your training and employment documents with your application. Do not ask your training employer to send documents directly to the Department.
5
II
California Department of Health ServicesSample Documents (February 1995)
PROOF OF EXPERIENCE SAMPLE FORM
Department of Health Services - Childhood Lead Poisoning Prevention Branch Complete one form for each employer providing verifiable proof of your experience. Type or print ail information. You may use a photocopy or a computer-generated facsimile of this form. Include all information on computer facsimiles.
1. Applicant Information:
Name:.: Last
First
State of California Contractor's License Number: (it applicable)________
I am using experience from the following employer to satisfy my eligibility requirement for: (check ail that apply)
Inspector/Assessor Q Supervisor
Q Project Monitor Q Project Designer
Q Ail or part of my education requirement
2. Employer Information:
Company Name:j
Address:
Number
Street
Suite
City
State
Zip
Supervisor Name:
Last
First
Supervisor Phone Number: ()-________________
Fax : ()-
3. Experience Information:
Describe the lead-related construction or other applicable activities the applicant has performed while working for the above employer. (Use extra pages If necessary.)
(Continued onpages which are hereby attached and made a pari hereof.) Dates employed to do the work described above.
From:
ft
Month Day
Year
To: II
Month Day Year
Percentage of time did the work described above. %
4. Declaration and Signature of Employer:
I certify, under penalty of perjury, that the information contained in this document is true and correct.
Emptoyer/Supervisor Signature
Print Narrie of Empioyer/Supervisor
Date Signed
Print Title of Empioyer/Supervisor
6 Lead-Related Construction Interim Certification, Application Instructions 49 TOC 002051
State of California - Health and Welfare Agency
Department of Health Services Childhood Lead Poisoning Prevention Branch
APPLICATION FOR LEAD-RELATED CONSTRUCTION INTERIM CERTIFICATION
1. Type Of Application:
a. Q Interim Certification
b. Q Renewal of Interim Certification
Note: Applicants for interim certification must apply to the Department within one year from the issuance date of the DHS Form 8493. Course Completion Form or the written documentation of completion of required instruction.
Applicants failing to apply within one year from the issuance date of the DHS Form 8493, Course Completion Form or the written documentation of completion of required instruction, must complete a minimum of seven contact hours of DHS-approved continuing education instruction to be eligible to apply for interim certification.
2. Applicants applying for renewal of Interim Certificate(s), please provide the following information:
Interim Certificate Number:
ExDiration Date:
//
Interim Certificate Number:
Excitation Date:
//
Interim Certificate Number:
ExDiration Date:
//
Interim Certificate Number: '
ExDiration Date:
//
Interim Certificate Number:
. Expiration Date:
//
3. Type Of Interim Certification:
Please check the box(es) for the type(s) of Interim Certificate(s) for which you are applying:
a. Q Lead-Related Construction Inspector/Assessor
d. Q Lead-Related Construction Project Monitor
b. Q Lead-Related Construction Supervisor
e. Q Lead-Related Construction Worker
c. Q Lead-Related Construction Project Designer
4. Applicant Information: (Please Print or Type)
Name:
Last
.. . . - ................. First
........ . M.l.
Residence Address: _;....................................................................................................................................... ....... ... ........................ -.
Number
Street
Apt
Mailing Address: (H different from above)
City
...................................... ,............. ............... Number
............. Street
.... .
State
Zip
-w..-./ . t.,-::Apt.
Phone Number: (_
City
State
Date of Birth: _______/______ / Month Day Year
Zip
Photo Identification Number (From Course Completion Form)-.
Gender:
Q Male
Q Female
Race/Ethnicity (checkone): Q White Black/African American Q Other (please specify)
5. Social Security Number ('Optional):
DHS Form 8438 (4/941
DO
American Indian Asian/Pacific Islander
(check one): Q Hispanic Q Non-Hispanic
49 TOC 002052
6. Documentation Of Applicant's Education, Training, And Experience:
Please enclose the following information with this application.
a. Lead-related construction training: Original DHS Form 8493, Course Completion Form for a course or continuing education instruction issued by an accredited training provider, OR written documentation of completion of required instruction, issued by a training provider. Documentation must include the name and address of the training provider, title of the course, dates of successful completion of the course and final course examination, number of course contact hours, and outline or syllabus of course content and time devoted to each topic. Documentation must include the name, printed or typed, date, signature, and title of the individual responsible for verifying, under penalty of perjury, that the information is true and correct.
b. Experience: Written documentation of experience, if applicable. Documentation must include name and address of employer, name and telephone number of supervisor; or indicate if self-employed. Documentation must also include employment dates, description of specific duties performed, and estimated percentage of time associated with lead-related construction activities. This information must be signed by the supervisor or employer verifying, under penalty of perjury, that the information is true and correct.
c. Education: Evidence of completion of postsecondary education, such as transcript or diploma, if applicable.
7. Please enclose two passport size photographs.
8. Renewal Applicants: Please provide documentation of any changes which have occurred since submission of original
application. Applicants for renewal are not required to include previously submitted documentation, unless it is no longer current or valid. Renewal applicants must, however, include payment of the S75.00 application fee. for each certificate requested.
Applicants for interim certification renewal must apply to the Department at least 120 calendar days prior to the expiration date indicated on the Interim Certificate.
9. Change Of Address: Interim certified individuals must notify the Department within 30 calendar days of a change of
address.
10. Applicant Verification Of Information:
I hereby certify, under penalty of perjury, that the information provided herein is true and correct.
Name;
Please Print or Type
Signature:.
Date: l /
11. Fees: Please enclose a $75.00 application fee for each Interim Certificate requested in the form of a cashier's check or
money order with this application payable to California Department of Health Services. Personal checks or cash will not be accepted.
*The Information Practices Act of 1977 and the Federal Privacy Act require the Department of Health Services to tell you why we ask you for information. The Childhood Lead Poisoning Prevention Branch asks for application information for interim certification of individuals engaged in lead-related occupations to carry out the requirements of the Health and Safety Code section 429.16. Disclosure of your Social Security number is voluntary.
Information furnished will be used for record keeping purposes and to correlate data bases containing lead poisoning cases to leadrelated construction activities performed.
We may give the information you furnish us to the Division of Occupational Safety and Health (Cal-OSHA) and California government agencies and officials, as provided by law.
You have the right to access records containing your personal information maintained by the Department of Health Services. The officials responsible for maintaining the information are located at the Childhood Lead Poisoning Prevention Branch, 5801 Christie Avenue, Suite 600, Emeryville, California 94608, Telephone: (510) 450-2447.
DHS Form S488 (4/94)
49 TOC 002053
2ol2