STATE OF
ILLINOIS
Division of Nuclear Safety
APPLICATION
FOR DEPARTMENT EVALUATION OF RADON CONTINUING EDUCATION
OFFICE OF
ENVIRONMENTAL SAFETY
RADON
PROGRAM
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Complete all items and use supplementary sheets where
necessary. Retain one copy and submit
the original to: Illinois Emergency Management Agency Division of Nuclear Safety, 1035 Outer Park Drive, Springfield, IL 62704, ATTN: Radon Program. If you have any questions contact the
Radon Program (800) 325-1245. This state agency is requesting disclosure of information
that is necessary to accomplish the statutory purpose as outlined under 32
III. Adm. Code 422. Disclosure of
this information is required. Failure
to provide any information may result in denial of radon continuing education
approval. |
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ITEM 1 |
Type of
Continuing Education (CE) |
(Check One) |
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[ ] Category I |
[ ] Category II |
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FOR
DNS / RADON
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* Note: Reference the 12
Convenient Ways To Earn Continuing Education Credits From DNS. |
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PROGRAM USE ONLY |
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ITEM 2 |
Person /
Company Offering Continuing Education |
(Check One) |
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Person / Company Name: |
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Received: |
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Responsible Individual: |
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Business Address: |
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[ ] Syllabus |
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City, State, Zip Code: |
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Business Telephone: |
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Fax: |
( ) |
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[ ] Resumes /
Biographies or |
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Email Address: |
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Credentials |
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FEIN / Social Security No.: |
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(List
Instructors Here) |
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ITEM 3 |
Advancing
Basic Knowledge |
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Continuing education needs to advance radon licensee
knowledge above the basic or qualification level. Briefly explain how your continuing education event achieves
this goal. |
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ITEM 4 |
Intended
Audience |
(Check One) |
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[ ] Agenda &
Time Allocated |
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Radon License Category: |
[ ] Measurement |
[ ] Mitigation |
[ ] Both |
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Pre-requisites, if any: |
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[ ] Completion
Criteria |
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ITEM
5
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Submittals
to the Department
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Event Title: |
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[ ] Event
Certificate |
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Total hours of supervised instruction: |
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Submit a separate application for each CE
event. |
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Presentation Dates: |
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Provide materials in accordance with 32 Illinois
Administration Code, Part 422, Section 422.85 and/or the method under which
you are seeking continuing education approval in the 12 Convenient Ways To Earn Continuing Education Credits From DNS. |
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ITEM 6 |
Certification |
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I certify that this continuing education event shall be
performed in accordance with the statements, representations, descriptions,
and examples contained, referenced in, or enclosed with the documents in this
application, or as modified in the evaluation process, and as approved by
Illinois Emergency Management Agency Division of Nuclear Safety. |
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FOR
DNS / RADON
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Manager Responsible for the Course |
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Date |
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PROGRAM
USE ONLY
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IL473-0329 (Rev. 1, 11/01)