Attachment 5 -Form 9600-051

Form Approved OMB No. 2070-0195 Expires x/xx/24
Lead-Based Paint Activities and Renovation
US Environmental Protection Agency

Post-Training Notification
Important: The training program manager may complete this sample form or similar form when notifying the EPA. Consult the
Instructions for Notifying the EPA of Lead-Based Paint Abatement Activities and Renovation Courses when preparing posttraining notification. Please type or print responses in black or blue ink only.

A. Type of Notification
Original

(Please indicate the type of notification)

Updated

B. Training Program
Accreditation Number:_

Name:_

Address:

Street Address

City

State

Zip Code

Phone Number:_

C. Course Information
Discipline:

Worker
Renovator

Supervisor
Inspector
Dust Sampling Technician

Type:

Initial

Refresher

Training Dates: from

Risk Assessor

Project Designer

to

Month/Day/Year

Month/Day/Year

Training Location Address:
Street Address

City

State

Zip Code

D. Student Information (Attach additional paper if necessary)
Name

Date of
Birth

Address

D. Training Managers Information

Course
Certificate #

Course
Photo
Certification
Test Score Included* expiration**

(Please note that this form is incomplete without a signature)

I hereby attest and affirm that the information included on this notification form is true and accurate to the best of my belief and
knowledge. I acknowledge that any approval authorized pursuant to this notification will be subject to revocation if issuance was
based on incorrect or inadequate information that materially affected the decision to issue the approval.
Name_
Signature_
Date Signed
*A photo of each student is required for Renovator and Dust Sampling Technician courses.
**The certification expiration date is required for Renovator initial and refresher trainings.
Please see www.epa.gov/lead/pubs/trainerinstructions.htm for photo specifications. The photos should be sent on a CD along
with this form.

EPA Form 9600-051

For information on EPA and other lead programs, see
the web site:
http://www.epa.gov/lead 

Privacy Act Statement
Authority: 40 C.F.R. Part 745, and 15 U.S.C. §§ 2682 and 2684.
Purpose: Information collected in this system is used to establish an applicant’s eligibility for 1) certification to
conduct lead-based paint and renovation, repair and painting (RRP) activities in target housing and childoccupied facilities; and 2) accreditation to teach lead-based paint and RRP activities training courses. In addition,
certification and accreditation information, as well as information collected from required notifications are used
for compliance monitoring, enforcement purposes, and related research.
Routine Uses: EPA may disclose collected information as necessary pursuant to the routine uses published in the
Privacy Act System of Records Notice: Federal Leadbased Paint Program (FLPP) System of Records, EPA-54, F.R.
87 Fed. Reg. No. 201 (October 19, 2022), found at https://www.federalregister.gov/
documents/2022/10/19/2022-22271/privacy-act-of-1974-system-of-records. Such disclosures may include, but
are not limited to, disclosure to the appropriate federal, state, local, foreign, tribal or other public authority
where relevant to the issuance or retention of a license, grant, or other benefit; to contractors, grantees,
consultants, volunteers, educational institutions, or research organizations for research purposes; or to
contractors, grantees, consultants, or volunteers as necessary to perform their duties or activities for the
Agency.
Mandatory or voluntary disclosure and the effects on the individual of not providing information: Providing your
personal information is voluntary. However, failure to provide your personal information may prevent the
Agency from certifying an applicant to perform lead-based paint or RRP activities, or accrediting training
programs to teach lead-based paint and RRP activities
training courses.

This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et seq.
(OMB Control No. 2070-0195). Responses to this collection of information are mandatory (40 CFR 745). An
agency may not conduct or sponsor, and a person is not required to respond to, a collection of information
unless it displays a currently valid OMB control number. The public reporting and recordkeeping burden for
this collection of information is estimated to be 0.6 hours per response. Send comments on the Agency’s need
for this information, the accuracy of the provided burden estimates and any suggested methods for minimizing
respondent burden including through the use of automated collection techniques to the Director, Information
Engagement Division, U.S. Environmental Protection Agency (2821T), 1200 Pennsylvania Ave., NW, Washington,
D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed form to this
address.