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INDIANA STATE DEPARTMENT OF HEALTH

APPLICATION FOR RADON TESTER/MITIGATOR CERTIFICATION

LEAD AND HEALTHY HOMES PROGRAM

4-11

State Form 45703 (R4 / 4-11)

RADON MEASUREMENT SERVICES:

If you are applying for Primary Radon Tester, Secondary Radon Tester or Radon Laboratory Tester, list the specific type

of detector(s) you’re using and list the name of the state-certified lab analyzing the detector(s) (i.e. “femto-TECH 510 –

self analyzed, charcoal canisters and electric ion chamber detectors – analyzed by X Laboratories”).

Type of Service Provided:

PROVIDE PROOF:

A. Provide a photocopy of your RPP Photo ID card. Also, if you

C. If you are applying for Radon Laboratory Tester

are applying for Radon Laboratory Tester or Primary Tester,

Certification, you must:

enclose your RPP Listing Letter.

Provide proof of a Bachelor’s degree from an

B. If the Radon Laboratory Tester and/or Primary Radon Tester is

accredited university or college in the physical

using a radioactive source for calibration, list the Indiana State

sciences or engineering or a related field.

Department of Health Radioactive Materials Registration Number.

Radioactive Materials Registration Number:

ii.

Provide proof of a minimum of two (2) years of

full-time experience in radiation measurement.

FOR RE-CERTIFICATION:

Follow the instructions in this section only if the individual has been certified before with the Indiana State Department of Health in any

category. Provide proof of continuing education that was completed within the prior two (2) years and was obtained as follows:

At least six (6) contact hours of continuing education from a radon course. Provide written confirmation of attendance, signed by the course

instructor or the designee. OR Full-time employment for the prior two (2) years in any category of certification. Provide written confirmation of

full-time employment signed by the business owner or chief executive officer of the business which employed the individual.

AND Provide proof of current listing with the RPP.

Previous Indiana Certification Number(s):

Check here if applying for re-certification.

CERTIFICATION & SIGNATURE:

I have also read and agree to adhere to the [check the appropriate category(s)]:

EPA’s “Indoor Radon and Radon Decay Product Measurement Device Protocols”

EPA’s “Radon Mitigation Standards”

► IMPORTANT

•

Allow two (2) to three (3) weeks for processing of a complete application package and receipt of your license(s).

•

Make sure you have completed all appropriate sections of this application and have included all required addenda. Sign and date the

application and return it to the Cashier address shown on page one (1) of this application. Applications will be returned which are

incomplete or contain errors in response to any questions on the form and will result in a delay in processing and issuance of your license(s).

•

All information requested on this application is mandatory for the administration and processing of your license application pursuant to

410 IAC 5.1.

I hereby certify that there are no misrepresentations in or falsifications of information submitted in this application. I understand that

should investigations disclose any falsification of information submitted in this application, my certification(s) may be revoked. I

understand that failure to comply with requirements as outlined within federal or state radon-related regulations may result in

civil and/or criminal penalties.

SIGNATURE OF APPLICANT: ________________________________________________

DATE SIGNED:

If you move, you must notify the Indiana Lead and Healthy Homes Program of your new address. Failure to do

so will result in a delay in certification. Omission of any of the required documents or incomplete or erroneous

information will result in your application being returned to you and a delay in certification.

State Form 45703 - Application For Radon Tester / Mitigator Certification - Indiana State Department Of Health Page 2

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