New Jersey Department of Health

Consumer, Environmental and Occupational Health Service

P. O. Box 372, Trenton, NJ 08625-0372	FACILITY INSPECTION WORKSHEET - ASBESTOS
Name of Training Agency

Training Agency Number

Date of Inspection

Street Address

Courses Agency Applied for/Approved

Worker (Initial and Refr.) Supervisor (Initial and Refr.)
City

State

Zip Code

Telephone Number

( )	Fax Number

( )
Type of Inspection
Pre-Certification New Facility Renovated 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.
Yes	No	N/A	Description	Yes	No	N/A	Description
1. Training Information Record (ASB-24)
4. Equipment, Supplies (Continued)
a. Secure (locked) location
l. Danger signs (5)
b. Account log of forms
m. 6 ml poly sheeting (1 case)
c. Other:
n. Other barrier supplies
2. Classroom
o. Pumps and filters (2)
a. Adequate size for (no.) ______ trainees
p. Other:
b. Adequate lighting
5. Hands-On Training Area
c. Writing surface (desks, tables, etc.)
a. Adequate size (see number in 2.a.)
d. Adequate seating (see number in 2.a.)
b. Adequate lighting
e. Adequate ventilation
c. Adequate ventilation
f. Comfortable temperature
d. Comfortable temperature
g. Acceptable background noise
e. 3 (minimum) chamber decon system
h. Other:
f. Adequate airlock widths
3. Audio Visual
g. Three-flap airlock system
a. Up-to-date/relevant videos/DVDs
h. Air differential opening
b. Working equipment
i. At least 2 critical barriers
c. Legible/understandable overhead slides
j. Removal substrate present
4. Equipment, Supplies
k. Removal substrate has cracks, crevices, and/or rough surfaces
a. Air differential unit (1)
b. HEPA vacuum (1)
l. Other:
c. Amended water applicators (5)
m. Other:
d. 6 mil waste bags, properly labeled (1 case)
6.	Total sq. footage of simulated surfacing asbestos material:	_______
e. Disposable clothing (1 case)
f. Glovebags (1 case)
7.	Type of simulated surfacing asbestos material:	_______
g. Duct tape (1 case)
h. Ladders (2)
8.	Total linear feet of simulated asbestos material for glovebag:	_______
i. Scaffolds (1)
j. Specialized abatement tools
9.	Number of simultaneous glovebag operations:	_______
k. Ground fault circuit interrupters (3)
10. Brands of

Respirators Used	Brand 1:	Brand 2:
Amount	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
Brand 1
Brand 2
Comments

Inspection Results

Satisfactory Unsatisfactory

Conditionally Satisfactory (see comments)	Maximum No. of Trainees

Name of Inspector (Print)

Signature of Inspector	Date

Name and Title of Training Agency Representative (Print)

Signature of Training Agency Representative	Date

ASB-26 JUN 14

ASB-26, Facility Inspection Worksheet-Asbestos

Elaine White

2004-12-22

ewhite

NJDOH