Oregon DHS Applications home
|Lead-Based Paint Activities and Renovation |[pic] |
|Pre-Training Notification | |
| | |
|Important: Training providers must submit the Pre-Training Notification to the Oregon Health Authority (OHA) at least seven (7) business days prior to the start |
|date of the course. |
| |
|1. Notification type (choose one): | Original | Updated | Cancellation |
| |
|If this is an update or cancellation, please show original date(s): | |
|2. Training program information: |
| |
|Name: | |Accreditation number: | |
| | | |(example: 41R050) |
|Address: | | | | |
| |Street |City |State |ZIP code |
| |
|Phone number: | |Email: | |
| |
|3. Course information (information in this section will be posted on the OHA website): |
| |
|Discipline: | Project designer | Inspector | Dust sampling technician |
| |Supervisor |Risk assessor |Renovator |
| |Worker | | |
| | | | |
| | | | |
| |
|Type: | Initial | Refresher |
| |
|Language presented (choose one): | English | Spanish | Other: | |
| |
|Training dates: | | | |
| |
|Date(s) (month/day/year) |Start time (H:MM) |End time (H:MM) |
| | | am / pm | | am / pm |
| | | am / pm | | am / pm |
| | | am / pm | | am / pm |
| | | am / pm | | am / pm |
| | | am / pm | | am / pm |
|(attach additional sheets, if needed). |
| |
|Principal instructor (name): | |Phone: | |
| |
|Guest instructor(s) (if any): | |
| |
|Training location name (if applicable): | |
| |
|Training location address: | | | | |
| |Street |City |State |ZIP code |
| | | | | |
| | | | | |
|Training manager (print) | |Training manager signature | |Date |
|Send completed form to: Oregon Health Authority |
|800 NE Oregon Street, Suite 640 |
|Portland OR 97232 |
|Fax: 971-673-0457 |
|Email: lead.program@state.or.us |
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