Form Sample Form Sample Form Lead-Based Paint Activities and Renovation Post-Training

US Environmental Protection Agency

Lead-Based Paint Activities and Renovation

Important: The training program manager may complete this sample form or similar form when notifying the EPA. Consult the
Instructions for Notifying the EPA of Lead-Based Paint Abatement Activities and Renovation Courses when preparing posttraining notification. Please type or print responses in black or blue ink only.

A. Type of Notification
Original

(Please indicate the type of notification)

Updated

B. Training Program
Name:________________________________________

Accreditation Number:________________________________

Address:______________________________________________________________________________________________
Street Address

City

State

Zip Code

Phone Number:_______________________________

C. Course Information
Discipline:

Worker
Renovator

Supervisor
Inspector
Dust Sampling Technician

Type:

Initial

Refresher

Risk Assessor

Project Designer

Training Dates: from________________ to _________________
Month/Day/Year

Month/Day/Year

Training Location Address:________________________________________________________________________________
Street Address

__________________________________________________________________________________________
City

State

Zip Code

D. Student Information (Attach additional paper if necessary)
Name

Date of
Birth

Address

D. Training Managers Information

Course
Certificate #

Course
Test Score

Photo
Included*

(Please note that this form is incomplete without a signature)

I hereby attest and affirm that the information included on this notification form is true and accurate to the best of my belief and
knowledge. I acknowledge that any approval authorized pursuant to this notification will be subject to revocation if issuance
was based on incorrect or inadequate information that materially affected the decision to issue the approval.
Name_____________________________

Signature__________________________

Date Signed_________________

*A photo of each student is required for Renovator and Dust Sampling Technician courses.
Please see www.epa.gov/lead/pubs/trainerinstructions.htm for photo specifications. The photos should be sent on a CD along with this form.

For information on EPA and other lead programs, see the web site:
http://www.epa.gov/lead