New Jersey Department of Health

Consumer, Environmental and Occupational Health Service

Indoor Environments Program

PO Box 372, Trenton, NJ 08625-0372

Telephone: 609-826-4950 Fax: 609-826-4975	LEAD

TRAINING Course

nOtification
All course information must be completed or the course will not be recognized. Please type or print legibly. Illegible notifications will be rejected. Notifications must be received by the NJDOH at least five (5) days but no more than two (2) weeks from the beginning of the course.
NOTIFICATION TYPE
Initial Notification:	New Notification

Subsequent Submissions:	Revision (indicate changes in Comments below) Cancellation
GENERAL COURSE INFORMATION
Unique Course ID Number

(assigned by Training Agency)

Training Agency Name

Training Agency Number

First Day of Class

Last Day of Class (leave blank for Refresher Course)

Days are not consecutive

Indicate non-consecutive Days in Comments.	Course Times

Approx. # of Students

*If class dates are not consecutive, each individual day must be indicated in the “Comments” section (below).

Reminder: All course agendas must be approved by the NJDOH before using it in a NJ-certified course.
Type of Course:

A. Initial B. Refresher	Course Language:

1. English 2. Spanish 3. Polish
Course Discipline (check one):

A. Worker-Housing and Public Buildings	D. Planner/Project Designer

B. Supervisor-Housing and Public Buildings	E. Worker-Commercial Buildings and Superstructures

C. Inspector/Risk Assessor	F. Supervisor-Commercial Buildings and Superstructures
INSTRUCTORS

All Course Instructors must be approved by the NJDOH in accordance with N.J.A.C. 8:42-4.5 prior to instructing a NJ-certified course.
General Lecture Instructor(s)

Health Effects/PPE Instructor(s)

Work Practice Lecture Instructor(s)

Work Practice Hands-on Instructor(s)

LECTURE LOCATION
Street Address

Name of Contact Person

City	State

Telephone

Fax

HANDS-ON / SITE VISIT LOCATION Check here if Not Applicable
Street Address

Name of Contact Person

City	State

Telephone

Fax

Comments

In accordance with N.J.A.C. 8:62-4.4, if the course information changes, your agency must notify this office as soon as you become aware of such changes.
Name and Title of Person Submitting Notice (Print)

Signature

Date

EHS-21

JUL 12

EHS-21, Lead Training Course Notification

EHS-21, EHS, lead, training, course, notification, indoor environment program

ewhite

2011-05-09

NJDOH