Fillable Commonwealth of Massachusetts DW Request for TCH Application Form

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Commonwealth of Massachusetts DW Request for TCH Application Form

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The Commonwealth of Massachusetts DW Request for TCH Application Form form is 2 pages long and contains:

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  • 7 check-boxes
  • 26 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Commonwealth of Massachusetts

BROWSE COMMONWEALTH OF MASSACHUSETTS (MA) FORMS

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Board of Certification of Operators of Drinking Water Supply Facilities
Division of Registration
1000 Washington Street
•
Suite 710
Boston
•
Massachusetts
•
02118-6100
Information:
Name/Association:
Address: ________________________________ __________________ ______ _________
Number and Street Name City/Town State Zip Code
Name of Person Requesting TCHs:
Day Phone: _______________ Fax: _______________ email:
Program/Course Title:
Program/Course Location:
Dates of Program/Course:
Individual Training Course:
How will this course meet the needs of Certified Public Water Supply Operator? What will (s)he
learn?
Instructor’s Name:
Address: ________________________________ __________________ ______ _________
Number and Street Name City/Town State Zip Code
Qualifications (or attach resume):
Continued on next page
This box for DEP use.
Date Received
Evaluated By
Date
Evaluated
Board
Approval
Number of
TCHs
Board File Number
Request for Training Contact Hours (TCH) Application Form
Individual Training Course Continued:
Proctor’s Name:
Affiliation, Address, Phone:
Be sure to enclose with this application:
0
The
course outline or agenda
showing each topic covered and the time allotted for each
topic.
0
A copy of the instruction material showing what skills and knowledge the student will be
able to demonstrate after completion of the course. And enclose a copy of all handouts or course
materials. Enclose a list of all audiovisual material used in the course (videos, slides, tapes,
films, overheads, etc.).
0
A
copy of the Certificate of Completion
.
0
A
copy of the attendance roster
that will be used.
(Showing the name of the course, renewal credits issued, course id number, date and time the
course was held, location of course, instructor’s name, attendees names, morning and afternoon
sign in and each day sign in, operator certificate number if applicable, proctor affidavit)
0
A
copy of the course’s evaluation form.
0
A
copy of the written policy on maintaining the course’s records
.
0
A
copy of the course’s requirements of satisfactory completion
(performance and
attendance) of the course.
Number of Training Contact Hours requested.
If approval of a training program is desired over individual courses please contact Paul Niman
at 617-556-1166 or email at paul.niman@state.ma.us
training\applicat2.doc
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Commonwealth of Massachusetts DW Request for TCH Application Form

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Completed 15 May 2020

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