Note to Applicant: Before completing this application form, read and become familiar with 10 NYCRR Part 73, the Asbestos Safety Program
Requirements. Part 73 provides topics and requirements for initial and refresher training courses, administrative requirements, instructor
qualifications, required examinations and revocation standards. An incomplete application will be returned to the applicant.
1. Purpose of Submittal (Please check one box ONLY.)
Applicant seeking accreditation as a New York State Asbestos Safety Training Provider
Applicant holds New York State accreditation and is submitting new/revised curriculum Provider#
2. Training Program Curriculum(s) Submitted (Please check all those that apply to this application.)
Contractor/Supervisor Initial Refresher
Handler/Worker Initial Refresher
Project Monitor
Initial Refresher
Air Sampling Technician Initial Refresher
Management Planner Initial Refresher
3. Supplements to the Application (To be completed by all applicants.)
Append to this application the following:
1. List by title any previous asbestos course(s) conducted.
2. List all other licensing/certification authorities for which asbestos course(s) have been approved.
3. Starting date of scheduled course(s) for programs contained in this application.
4. Indicate whether applicant or proposed training personnel have been found in violation of State or Federal asbestos regulations.
If yes, provide a detailed narrative.
4. Submittal Checklist for New Applicants and New York State Accredited Training Providers Submitting New or
Revised Curriculum
Page 2 of this application contains a checklist of documents and statements that must be included in the application.
New applicants must complete Sections 1 and 2. Accredited New York State Training Providers must complete Section 2 only.
5. Applicant Verification Statement
The applicant attests that the information contained in this application is accurate, true and complete to the best of the applicant’s knowledge
and that false statements made in this application are subject to the applicable provisions of the New York State Penal Law. Submission of a
false statement is grounds for disapproval of this application.
Completed by Signature Date
Application for Approval or Revision of an
Asbestos Safety Training Program
Bureau of Occupational Health and Injury Prevention
DOH-2134A (9/13) Page 1 of 2
Pursuant to Article 30, Section 905 of the New York State Labor Law
as required under Title 10, Chapter II; Subchapter H, Part 73 NYCRR,
Asbestos Safety Program Requirements,” application is hereby made
for a certificate of approval to sponsor the training courses required
for certification in New York State.
Asbestos Safety Training Program
Corning Tower Room 1325
Empire State Plaza
Albany, NY 12237
518-402-7940 (phone)
518-402-7949 (fax)
Operations & Maintenance
Initial Refresher
Inspector Initial Refresher
Project Designer Initial Refresher
Allied Trades Initial Refresher
Company Name Phone Number Fax Number
City State Zip Code Email
Application for Approval or Revision of an
Asbestos Safety Training Program
Bureau of Occupational Health and Injury Prevention
DOH-DOH-2134A (9/13) Page 2 of 2
Section 1 – Application Requirements (To be completed by new applicants ONLY.)
This section summarizes the submittal requirements for those applicants seeking accreditation for the first time. Applicants must refer to Part 73 for
the complete text of the requirements that address the administrative infrastructure identified below. All documents and statements submitted must be
accurate, complete and reference the applicable regulation section. Plans and procedures for meeting these requirements must be part of each application.
Training Director – Each asbestos safety training provider must have designated, at all times, a Training Director who is approved by the
Department. The name and credentials of the Training Director shall be submitted for Department review with each application for
accreditation of an asbestos safety training program and whenever a new Training Director is designated. The Training Director shall have
experience in designing, implementing and evaluating either employee educational programs in asbestos safety or vocational educational
programs related to asbestos. The Training Director shall be directly involved in the program. Evidence that the proposed Training Director
meets the qualifications must be included in the application;
Instructors – Only approved instructors may be used to give instruction in a program accredited by the Commissioner. Submit names and
resumes of proposed instructors that meet the minimum qualifications as described in section 73.4;
Facilities – A description of the training facility(ies) including a diagram or blueprint which identifies classrooms with their respective area
dimensions, record keeping location(s), and equipment storage location(s). If records are to be stored at a location other than the training
facility, the address and site specific information on the record storage room must be included. Application must include a statement that
facilities and equipment will be available and sufficient to accommodate students’ needs;
Provider Profile – A detailed description of the training provider’s management and corporate structure including individual names of
management personnel and corporate officers. The detailed description must include details of other business affiliations including,
but not limited to, affiliations with asbestos abatement firms, environmental sampling and analysis firms and manpower brokerage firms;
Quality Assurance Program – Submit procedures pursuant to Subdivision 73.2(e);
Languages – The application for a language other than English must be submitted as specified in Subdivision 73.2(k);
Record Keeping – The training provider must submit a detailed record keeping procedure which identifies the type of records to be maintained
as described in Subdivision 73.3(1) and the security measures that will be implemented to ensure the integrity of the records;
Program Changes – Applicant must describe the procedures used to notify the Department in writing of any changes in any respect of an
accredited training program.
Section 2 – Application Requirements (To be completed by new applicants & New York State accredited Training Providers submitting
new or revised curriculum.)
This section summarizes the submittal requirements for all applicants seeking accreditation. Applicant must refer to Part 73 for the complete text
of requirements to the items listed below. All documents, student manuals, and statements submitted must be accurate and complete. Manual(s)
must not contain grammatical or typographical errors.
Course Outline – Submit a detailed outline of each program/course including the length of training, the amount of time allotted to each topic,
and a description of the type of teaching method for each topic;
Student Manual(s) – Applicant must provide one (1) copy of the entire student manual along with all other written materials, and regulations,
intended to augment the student manual;
Equipment – Include a description of all materials and equipment to be used for hands-on practice exercises and demonstrations in accor-
dance with Subdivision 73.3(h);
Training Procedures – Submit a copy of the instructor lesson plan(s) and transparencies, slides, and audio-visual materials to be used to
supplement the program presentation. The training provider must detail those interactive/participatory teaching methods to be used and in
which topic areas they will be employed;
Examination(s) Applicant must provide a copy of each examination with the appropriate answer key. Answer key must include the correct response;
Course Evaluation Form Include a copy of the student evaluation form;
Accredited Providers Only – Submit instructor approval requests per Subdivision 73.2(b) and describe any other program change(s) in
accordance with Subdivision 73.2(i).
Department Approval
Provisional accreditation shall be granted after a full review of the program application has been completed. If approval is granted, a letter of
provisional accreditation shall be sent to the applicant. In the case of disapproval, a letter describing the reasons for disapproval shall be sent
to the applicant. Prior to disapproval, the Department may request additional information to address inadequacies in the application for
accreditation. If an application is disapproved by the Department, the applicant may reapply for accreditation at any time.