Training Notification For Lead-Based Paint Activities Form
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1FOR OFFICIAL USE ONLY
Date Received: _____________
Rec. Number: ______________
Comments: ________________
TRAINING NOTIFICATION for Lead-Based Paint Activities
Please type or print responses in black or blue ink.
A. Type of Notification
Original
Updated
Cancellation
(choose one)
B. Description of Training
Course Discipline:
Course Type:
Language
Worker
English
Initial
Presented:
(choose one)
(choose one)
Supervisor
Refresher
Spanish
(choose one)
Inspector
Other: ______
Risk Assessor
Project Designer
(Enclose additional sheets if necessary.)
Date(s)
Start Time
End Time
Month/Day/Year
AM/
PM
AM/
PM
AM/
PM
AM/
PM
Principal Instructor: ____________________________________________________________________________
Training Location Name
: ____________________________________________________________
(if applicable)
Training Location Address: ______________________________________________________________________
Street Address
______________________________________________________________________
City
State
Zip Code
Training Location Phone Number: (_____)_____________________
C. Training Program
Name: ____________________________________________ Accreditation Number: ____________________
Address: _________________________________________________________________________________
Street Address
City
State
Zip Code
Phone Number: (_____)______________________
D. Training Manager's Information
(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 ____________
SEND TO:
STATE DEPARTMENT OF HEATLTH
INDOOR AND RADIOLOGICAL HEALTH BRANCH
LEAD-BASED PAINT SECTION
591 ALA MOANA BOULEVARD, #133
HONOLULU, HI 96813
PHONE (808) 586-5800 FAX (808) 586-5811
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