CERTIFICATE OF WORKER'S ACKNOWLEDGMENT
PROJECT NAME _________________________ CONTRACT NO. ______________________
PROJECT ADDRESS __________________________________________________________
CONTRACTOR FIRM NAME _____________________________________________________
EMPLOYEE'S NAME _________________________,_______________,______,
(Print)
(Last)
(First)
(MI)
Social Security Number:
_______-_______-________,__(Optional)
WORKING WITH ASBESTOS CAN BE DANGEROUS. INHALING ASBESTOS FIBERS HAS
BEEN LINKED WITH TYPES OF LUNG DISEASE AND CANCER. IF YOU SMOKE AND
INHALE ASBESTOS FIBERS, THE CHANCE THAT YOU WILL DEVELOP LUNG CANCER
IS GREATER THAN THAT OF THE NONSMOKING PUBLIC.
Your employer's contract for the above project requires that you be provided
and you complete formal asbestos training specific to the type of work you
will perform and project specific training; that you be supplied with proper
its use; and that you receive a medical examination to evaluate your physical
capacity to perform your assigned work tasks, under the environmental
conditions expected, while wearing the required personal protective
equipment. These things are to be done at no cost to you. By signing this
certification, you are acknowledging that your employer has met these
obligations to you. The Contractor's Designated Industrial Hygienist will
check the block(s) for the type of formal training you have completed.
Review the checked blocks prior to signing this certification.
FORMAL TRAINING:
_____ a. For Competent Persons and Supervisors: I have completed EPA's
Model Accreditation Program (MAP) training course, "Contractor/Supervisor",
that meets this State's requirements.
b.
For Workers:
_____
(1) For OSHA Class I work: I have completed EPA's MAP training
course, "Worker", that meets this State's requirements.
_____
(2) For OSHA Class II work (where there will be abatement of more
than one type of Class II materials, i.e., roofing, siding, floor
tile, etc.): I have completed EPA's MAP training course, "Worker",
that meets this State's requirements.
(3) For OSHA Class II work (there will only be abatement of one
type of Class II material):
_____
(a) I have completed an 8-hour training class on the elements
of 29 CFR 1926.1101(k)(9)(viii), in addition to the specific work practices
and engineering controls of 29 CFR 1926.1101(g) and hands-on training.
_____
(b) I have completed EPA's MAP training course, "Worker",
that meets this State's requirements.
_____
(4) For OSHA Class III work: I have completed at least a 16-hour
course consistent with EPA requirements for training of local education
agency maintenance and custodial staff at 40 CFR 763, Section .92(a)(2) and
the elements of 29 CFR 1926.1101(k)(9)(viii), in addition to the specific
work practices and engineering controls at 29 CFR 1926.1101, and hands-on
training.
SECTION 13280A
Page 59