New Jersey Department of Health

Consumer, Environmental and Occupational Health Service

Environmental and Occupational Health Assessment Program

PO Box 369, Trenton, NJ 08625-0369

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

TRAINING Course

nOtification
All course information must be completed or the course will not be scheduled. 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;

See Comments*.	Course Times

Approx. No. of Students

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

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

1. Initial

2. Refresher	Course Discipline (check one):

1. Worker

2. Supervisor	Course Language:

1. English	3. Polish

2. Spanish	4. Serbian
INSTRUCTORS

All Course Instructors must be approved by the NJDOH in accordance with N.J.A.C. 8:60-6.5 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. 8:60-6.4, if the course information changes, your agency must notify this office as soon as you become aware of such changes.
Name of Person Submitting Notice (Print)

Signature

Date

EHS-37

JAN 13

EHS-37, Asbestos Training Course Notification

EHS-37, Asbestos, training, course, notification, EHS, indoor environments program

ewhite

2011-05-19

NJDOH