FORM G
POST-ATTENDANCE CONTACT HOUR
COURSE APPROVAL APPLICATION
State of Ohio Environmental Protection Agency
Division of Drinking and Ground Waters
Certification Unit
P.O. Box 1049
Columbus, Ohio 43216-1049
Phone (614) 644-2752 Fax (614) 644-2909
**Failure to fill out all of the required fields or submit all required information may result in** rejection of this course approval application.
Required Standards -For approval, the following standards must be met for each Contact Hour Course.
1.Application must be made within thirty (30) days of course completion.
2.Training must relate to the operation, maintenance or management of a drinking water and/or wastewater system.
3.A detailed course agenda that shows the duration of each course segment and notes any time for registration, breaks, lunch etc., must be submitted for all courses more than one (1) hour in length.
4.Instructors must be identified in advance or concurrently with this application.
5.A record of training activity including: course name, training site location, course date(s), operator ID, employer and verification of an individual’s successful completion, must be included with this application and sent to the Certification Unit at the address above.
6.Records must be maintained for a three (3) year period.
I. Applicant Information
1. Name / 2. Certification Number / 3. Core Person ID Number4. Telephone Number
5. Mailing Address
II. Course Information -Submit the following information on each course for which approval is sought. Reference to attachments may be noted in the appropriate space.
1. Course Title:Attach a timed agenda of sufficient detail for the Certification Unit to determine relevance to drinking water and/or wastewater system operations. (Include description of any visual aides or handouts used in the course.)
2. Date(s)/Location(s) of Training:
3. Actual amount of time spent in class (exclude breaks, lunch, etc.)
4. Detail the information learned from the course.
5. Instructional Format (Check all that apply): Classroom In-House Training Correspondence Course
Video (group setting) Other (describe)
6. Grade or verification of attendance:
7.Instructor:
Name Title Occupation
Professional Organization/Company/Agency Represented
Business Address Contact Phone #
Qualifications of Instructor, if not an accredited school:
8.Accredited college, university or school:
Name Contact Phone #
Address
9.Sponsoring Organization Information:
Name Contact Phone #
Address
Contact Name Title:
As the applicant for post-attendance credit, I confirm that all information provided with this application is accurate to the best of my knowledge.
Print Name:
Signature: Date:
The Advisory Board of Examiners and the Ohio EPA Certification Unit would like to call your attention to Ohio Administrative Code (OAC) Section 3745-7-12(A) which states: “The director may suspend or revoke the certification(s) of an operator, issued under this chapter, upon finding that the operator has: (1) Fraudulently obtained or attempted to obtain any certification or renewal thereof, or (2) Performed the duties of an operator in a grossly negligent or incompetent manner, or (3) Knowingly or negligently submitted misleading, inaccurate, or false reports to the Ohio EPA, or (4) Operated in a manner endangering the public health or welfare, or (5) Violated or caused to be violated any of Chapter 6109 or 6111 of the Ohio Revised Code.”
Electronic versions of applications and program updates may be found at:
INSTRUCTIONS FOR COMPLETING FORM G
POST-ATTENDANCE
CONTACT HOUR COURSE APPROVAL APPLICATION
Applications must be made within thirty (30) days of course completion.
I. Applicant Information:
1.The name of the certified operator submitting the application to receive post-attendance approval.
2.The certification number of the certified operator submitting the application to receive post-attendance approval.
3.The Core Person ID number of the certified operator requesting approval.
4.The telephone number of the certified operator requesting approval.
5.The mailing address of the certified operator requesting approval.
II. Course Information:
1.Write the name of the course.
2.List the date(s) and location(s) where the course was presented; indicate the date, the city and the location within the city.
3.Enter the actual amount of time spent in class, excluding breaks, lunch, etc.
4.A detailed description of the course content which provides an explanation of what was learned in the class.
5.Check the type of instructional format.
6.Provide proof of a passing grade. If the course is not graded, provide verification of attendance.
7.Provide the following information on the instructor: name, title occupation, professional affiliation, business address, and phone number. If the school providing the course is not accredited, the qualifications of the instructor should be listed.
8.Provide the name, phone number and address of the college, university or school where the course was taken.
9.If the course is provided by an organization other than mentioned above in #8 (e.g., conferences, etc.), please provide the name, phone number and address of the sponsoring organization with a contact person and their title.
Applicants shall sign and date each application for post-attendance contact hour approval. By signing, the applicant accepts full responsibility for all information submitted.
Electronic versions of applications and program updates may be found at: