CERTIFICATE OF WORKER'S ACKNOWLEDGMENT
_____
(5) For OSHA Class IV work: I have completed at least a 2-hr
course consistent with EPA requirements for training of local education
agency maintenance and custodial staff at 40 CFR 763, (a)(1), 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(g) and hands-on
training.
_____ c. Workers, Supervisors and the Designated Competent Person: I have
completed annual refresher training as required by EPA's MAP that meets this
State's requirements.
PROJECT SPECIFIC TRAINING:
_____ I have been provided and have completed the project specific training
required by this Contract. My employer's Designated Industrial Hygienist and
Designated Competent Person conducted the training.
RESPIRATORY PROTECTION:
_____ I have been trained in accordance with the criteria in the
Contractor's Respiratory Protection program. I have been trained in the
dangers of handling and breathing asbestos dust and in the proper work
procedures and use and limitations of the respirator(s) I will wear. I have
been trained in and will abide by the facial hair and contact lens use policy
of my employer.
RESPIRATOR FIT-TEST TRAINING:
_____ I have been trained in the proper selection, fit, use, care, cleaning,
maintenance, and storage of the respirator(s) that I will wear. I have been
fit-tested in accordance with the criteria in the Contractor's Respiratory
Program and have received a satisfactory fit. I have been assigned my
individual respirator. I have been taught how to properly perform positive
and negative pressure fit-check upon donning negative pressure respirators
each time.
EPA/[STATE] CERTIFICATION/LICENSE
I have an EPA/[_____] certification/license as:
Building Inspector/Management Planner; Certification #______
Contractor/Supervisor, Certification # _____________________
Project Designer, Certification # __________________________
Worker, Certification # ____________________________________
MEDICAL EXAMINATION:
_____ I have had a medical examination within the last twelve months which
was paid for by my employer. The examination included: health history,
pulmonary function tests, and may have included an evaluation of a chest
x-ray. A physician made a determination regarding my physical capacity to
perform work tasks on the project while wearing personal protective equipment
including a respirator. I was personally provided a copy and informed of the
results of that examination. My employer's Industrial Hygienist evaluated
the medical certification provided by the physician and checked the
appropriate blank below. The physician determined that there:
_____ were no limitations to performing the required work tasks.
_____ were identified physical limitations to performing the required work
tasks.
SECTION 13280A
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