Hazardous Materials - Government of New Jersey - fedex hazardous materials certification form

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Department of Community Affairs
Division of Fire Safety Hazardous Materials
Phone: (609) 777-3552 Certification Application Form
Fax: (609) 341-3469
1. SSN Number: _______________________________________________________ For Official Use Only
State DFS-ID Number: _________________________ (If previously issued - e.g., 111111)
Received: ________________
Name: _______________________________________________________
Returned: ________________
2. Titles: Hazardous Materials: Awareness
Hazardous Materials: Operations Date Issued: ________________
Hazardous Materials: Incident Commander
By:
Mission Specific Competencies: 6.2: Personal Protective Equipment (PPE)
Mission Specific Competencies 6.6: Product Control
Seeking Equivalency Determination. See page two of this form.
3. Hazardous Material Certification Titles and their Credentialing Requirements
Please check above the appropriate box(s) corresponding to the Hazardous Materials Level to be issued. You may apply for multiple
certification levels using this ONE application.
Submittal Instructions: Please provide the following documentation with your application: 1) Photocopy of your birth certificate or driver's
license; 2) instructional program completion certificates; and proof that you successfully passed the State final exams associated with the
certification level requested. Copies of State certification certificates should be included with the documentation to prove certifications
issued. Please note that certification will not be issued unless documentation has been received and validated.
Hazardous Materials: Awareness Credentialing Criteria: Be at least 18 years of age; Possess a NJ Firefighter I certification issued by the
NJ Division of Fire Safety; Successfully complete the NJ adopted Hazardous Materials: Awareness instructional program, and pass the State
exams that evaluate the Job Performance Requirements (JPR's) and components of requisite knowledge and skills contained in the most
current edition of the adopted NFPA 472 standard, specific to Chapter 4.
Hazardous Materials: Operations Credentialing Criteria: Be at least 18 years of age; Possess NJ Firefighter I and Hazardous Materials:
Awareness certifications issued by the NJ Division of Fire Safety; Successfully complete the NJ adopted Hazardous Materials: Operations
instructional program, and pass the State exams that evaluate the Job Performance Requirements (JPR's) and components of requisite
knowledge and skills contained in the most current edition of the adopted NFPA 472 standard, specific to Chapter 5.
Hazardous Materials: Incident Commander Credentialing Criteria: Be at least 18 years of age; Possess both the NJ Firefighter I and
Hazardous Materials: Operations certifications issued by the NJ Division of Fire Safety; Successfully complete the NJ adopted Hazardous
Materials: Incident Commander instructional program, and pass the State exams that evaluate the Job Performance Requirements (JPR's) and
components of requisite knowledge and skills contained in the most current edition of the adopted NFPA 472 standard, specific to Chapter 8.
Competencies for Operations Level Responders Assigned Mission-Specific Responsibilities:
Mission Specific Competencies-Personal Protective Equipment (PPE) Credentialing Criteria: Possess a Hazardous Materials: Operations
certification issued by the NJ Division of Fire Safety; Successfully complete the mission specific competencies for personal protective
equipment within the instructional program, and pass the State exams that evaluate the Job Performance Requirements (JPR's) and
components of requisite knowledge and skills contained in the most current edition of the adopted NFPA 472 standard, specific to Chapter
6.2.
Mission Specific Competencies-Product Control Credentialing Criteria: Possess a Hazardous Materials: Operations certification issued by
the NJ Division of Fire Safety; Successfully complete the mission specific competencies for product control within the instructional program,
and pass the State exams that evaluate the Job Performance Requirements (JPR's) and components of requisite knowledge and skills
contained in the most current edition of the adopted NFPA 472 standard, specific to Chapter 6.6.
4. I do hereby certify that the documentation submitted with this application is accurate and is true. I am aware that if any of the
documentation is willfully false, I am subject to punishment.
Applicant's Signature: _______________________________________________________________ Date: _________________________
Revised: Jan 2019
Hazardous Materials Certification Application Form Instructions
Please type or print clearly on the application form.
Certification will not be issued unless documentation is received and validated.
Section
1. Enter your Social Security Number (SSN) and six digit Firefighter Identification Number (FFID) if previously issued to you. Provide
your name. The collection of the SSN is mandatory, and is collected under authority of N.J.S.A. 54:50-24 et seq. and Administrative
Rule N.J.A.C. 5:3-1.2. The mandatory provision requires the collection of your SSN which enables both the Division of Fire Safety
within the Department of Community Affairs and the Division of Taxation within the Department of Treasury to conduct more
efficiently, the necessary background check before issuance, denial, renewal, suspension or revocation of a certification.
2. Hazardous Materials Certification Titles. Indicate by checking the box associated with the Title(s) to be certified. You may use this
form to apply for multiple titles at once.
3. Hazardous Materials Certification Titles Credentialing Requirements. Explained on the first page.
Please note that it shall be the responsibility of the employer to maintain the necessary documentation as set forth in the most current
edition of the NFPA 472 standard, that the individual certified through N.J.A.C. 5:73-6 has met the job performance requirements
associated with the certification title. A crosswalk document to reference would be 29 CFR 1910.120, which requires statements
from the employer that the employee is familiar with the criteria of 29 CFR 1920.120(q)(6)(v)(A) through (F). Regarding the
Hazardous Materials: Incident Commander certification title, the employer would need to document that the employee: Knows and
is able to implement the employer's incident command system; Knows how to implement the employer's emergency response plan
(SOP's & SOG's); Knows and understands the hazards and risks associated with employees working in chemical protective clothing
(selection of appropriate PPE); Knows how to implement the local emergency response plan (ERP); Knows of the state emergency
response plan and of the Federal Regional Response Team; and, Knows and understands the importance of decontamination
procedures.
Equivalence Determination Criteria Explained:
The equivalency determination is intended to be applied to out-of-state instructional programs accredited by ProBoard or IFSAC, or
applied to a program of instruction deemed "equivalent" to the State adopted instructional program and which meets the current
associated NFPA 472 standard JPR's at time of application submittal. The program submitted for review should be consistent with the
New Jersey adopted program instructional objectives and hours associated with its delivery.
Submittal Instructions: Please provide the following documentation with your application: 1) Photocopy of your birth certificate or
driver's license; 2) instructional program completion certificates; and proof that you successfully passed the State final testing
requirements identified for the hazardous materials title requested. Please note that certification will not be issued unless
documentation has been received and validated.
4. The application form must be signed and dated.
Forward the application form and supportive documentation to:
Attn: Hazardous Materials Certification Office Staff Contact Information
Office of Training and Certification Questions about Firefighter certification requirements and
Division of Fire Safety procedures should be directed to the staff of the Office of
P.O. Box 809 Training and Certification at (609) 777-3552 from 8:30
Trenton, NJ 08625-0809 a.m. to 4:00 p.m., Monday through Friday.
Revised: Jan 2019


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