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| CERTIFICATE OF WORKER'S ACKNOWLEDGMENT and RELEASE PROJECT NAME _________________________ CONTRACT NO.___________________ PROJECT ADDRESS __________________________________________________________ CONTRACTOR FIRM NAME _____________________________________________________ EMPLOYEE'S NAME _________________________,_______________,______, (Print) (Last) (First) (MI) Social Security Number: _______-_______-________, Your employer's contract for the above project requires that you be provided and you complete formal microbial training specific to the type of work you will perform and project specific training; that you be supplied with proper personal protective equipment including a respirator, that you be trained in its use; and that you receive a medical examination to evaluate your physical capacity to perform your assigned work tasks, under the environmental conditions expected, while wearing the required personal protective equipment. These things are to be done at no cost to you. By signing this certification, you are acknowledging that your employer has met these obligations to you. The Industrial Hygienist will check the block(s) for the type of formal training you have completed. Review the checked blocks prior to signing this certification. FORMAL TRAINING: _____ a. For Competent Persons and Supervisors: I have completed "Contractor/Supervisor", that meets this State's requirements FOR MICROBIAL ABATEMENT. ______b. For Workers: I have completed 40 hour of training covering the hazards of mold abatement, engineering controls, decontamination procedures, New York City Guidelines, EPA Mold Remediation in Schools and Commercial Buildings, ACGIH, IICRC Standards, and AIHA. PROJECT SPECIFIC TRAINING: _____ I have been provided and have completed the project specific training required by this project. My employer's Designated Industrial Hygienist and Designated Competent Person conducted the training. RESPIRATORY PROTECTION: _____ I have been trained in accordance with the criteria in the Respiratory Protection program. I have been trained in the dangers of handling and breathing microbial spores and in the proper work procedures and use and limitations of the respirator(s) I will wear. I have been trained in and will abide by the facial hair and contact lens use policy of my employer. RESPIRATOR FIT-TEST TRAINING: _____ I have been trained in the proper selection, fit, use, care, cleaning, maintenance, and storage of the respirator(s) that I will wear. I have been fit-tested in accordance with the criteria in the Contractor's Respiratory Program and have received a satisfactory fit. I have been assigned my individual respirator. I have been taught how to properly perform positive and negative pressure fit-check upon donning negative pressure respirators each time. MEDICAL EXAMINATION: _____ I have had a medical examination within the last twelve months which was paid for by my employer. The examination included: health history, pulmonary function tests, and may have included an evaluation of a chest x-ray. A physician made a determination regarding my physical capacity to perform work tasks on the project while wearing personal protective equipment including a respirator. I was personally provided a copy and informed of the results of that examination. My employer's Industrial Hygienist evaluated the medical certification provided by the physician and checked the appropriate blank below. The physician determined that there: _____ were no limitations to performing the required work tasks. _____ were identified physical limitations to performing the required work tasks. Date of the medical examination __________________ Employee Signature ______________________________________ date _______ Contractor's Industrial Hygienist Signature_____________________________________________ date ___________ |
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