Form IOCI 17-558 Application for Lead Worker Licensure and Renewal - Illinois

Form IOCI17-558 or the "Application For Lead Worker Licensure And Renewal" is a form issued by the Illinois Department of Public Health.

A PDF of the latest Form IOCI17-558 can be downloaded below or found on the Illinois Department of Public Health Forms and Publications website.

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Lead ID Number L -
Lead ID Number HDE -
FOR DEPARTMENT USE ONLY
Application for Lead Worker Licensure and Renewal
LEAD ABATEMENT WORKER APPLICATION
RENEWAL FOR LEAD ABATEMENT WORKER
$50.00
Annual licensure fee for applicants requesting an initial or the renewal of an existing license
$25.00
Late licensure fee if received after March 1
$25.00
Reinstatement licensure fee for each year if expired fewer than three years (Expired more than three years must submit
a new application)
*All Fees Are Non-refundable and Non-transferrable*
Must be at least 18 years of age.
Make remittances payable to Illinois Department of Public Health (IDPH)
Applicant’s Legal Information
Last Name:
First Name:
MI:
Mailing Address:
City:
State: ZIP Code: County:
Phone Number:
Fax:
Date of Birth
:
Social Security Number:
(mm/dd/yyyy)
E-mail:
Website
:
(if applicable)
In accordance with the requirements of the Illinois Administrative Procedure Act, 5 ILCS 100, IDPH requires the disclosure of your social security
number as part of the license application. Failure to provide your social security number shall result in the denial of your license application.
Employer Information
Company Name:
Phone Number:
Fax:
Mailing Address:
City:
State: ZIP Code: County:
E-mail:
Website
:
(if applicable)
It is required by law (5ILCS/100/10-65) that all applicants shall complete and sign the following statement: Failure to complete this
statement will result in the return of your application and delays in processing your license. Making a false statement may place you in
contempt of court. Please check only one of the choices below that best applies to you. Note: your license will not be issued until this
section is completed. (CHECK ONLY ONE BOX)
I AM more than 30 days delinquent in complying with any child support order.
I AM NOT more than 30 days delinquent in complying with any child support order.
This statement does not apply.
Public Information Disclosure: By making a selection below, you authorize IDPH to publish or withhold your business or personal
information on all IDPH listings. Applicants who DO NOT complete the below information will have their personal information included
in IDPH listings by default. Your signature further confirms your agreement to hold harmless and release IDPH from any liability arising
from release of the information authorized below.
Personal Information
Business Information
I do not wish to be listed
I hereby certify that the information submitted is true and valid and I understand that the Illinois
Attach a clear, current, color
Department of Public Health may deny, revoke or suspend my application for a Lead Professional
passport size (2” x 2” exact size)
License for knowingly making false or fraudulent claims.
photograph with tape here.
The picture shall have the
printed name of the applicant on
Signature:
Date:
the reverse side of the photo.
Licenses will not be issued
Important Notice: This state agency is requesting disclosure of information that is necessary to accomplish the
without an identification
statutory purpose as outlined under public law PA 87-175. Disclosure of this information is mandatory. Failure
photograph.
to provide any information could result in denial, revocation or suspension of the applicant’s license.
This application shall be signed and dated. Application forms are processed in the order they are received. Walk-in applicants will have their applications
added to that day’s work and the licenses mailed to them. E-mailed and faxed applications will not be accepted. Please allow 4 weeks for the
Department to process the application and send the license in the mail. For additional information you may contact the Illinois Lead Program at
217-782-3517. Mail to: Illinois Department of Public Health, Division of Environmental Health, Illinois Lead Program, 525 W. Jefferson St., 3rd Floor,
Springfield, IL 62761.
IOCI 17-558
Lead ID Number L -
Lead ID Number HDE -
FOR DEPARTMENT USE ONLY
Application for Lead Worker Licensure and Renewal
LEAD ABATEMENT WORKER APPLICATION
RENEWAL FOR LEAD ABATEMENT WORKER
$50.00
Annual licensure fee for applicants requesting an initial or the renewal of an existing license
$25.00
Late licensure fee if received after March 1
$25.00
Reinstatement licensure fee for each year if expired fewer than three years (Expired more than three years must submit
a new application)
*All Fees Are Non-refundable and Non-transferrable*
Must be at least 18 years of age.
Make remittances payable to Illinois Department of Public Health (IDPH)
Applicant’s Legal Information
Last Name:
First Name:
MI:
Mailing Address:
City:
State: ZIP Code: County:
Phone Number:
Fax:
Date of Birth
:
Social Security Number:
(mm/dd/yyyy)
E-mail:
Website
:
(if applicable)
In accordance with the requirements of the Illinois Administrative Procedure Act, 5 ILCS 100, IDPH requires the disclosure of your social security
number as part of the license application. Failure to provide your social security number shall result in the denial of your license application.
Employer Information
Company Name:
Phone Number:
Fax:
Mailing Address:
City:
State: ZIP Code: County:
E-mail:
Website
:
(if applicable)
It is required by law (5ILCS/100/10-65) that all applicants shall complete and sign the following statement: Failure to complete this
statement will result in the return of your application and delays in processing your license. Making a false statement may place you in
contempt of court. Please check only one of the choices below that best applies to you. Note: your license will not be issued until this
section is completed. (CHECK ONLY ONE BOX)
I AM more than 30 days delinquent in complying with any child support order.
I AM NOT more than 30 days delinquent in complying with any child support order.
This statement does not apply.
Public Information Disclosure: By making a selection below, you authorize IDPH to publish or withhold your business or personal
information on all IDPH listings. Applicants who DO NOT complete the below information will have their personal information included
in IDPH listings by default. Your signature further confirms your agreement to hold harmless and release IDPH from any liability arising
from release of the information authorized below.
Personal Information
Business Information
I do not wish to be listed
I hereby certify that the information submitted is true and valid and I understand that the Illinois
Attach a clear, current, color
Department of Public Health may deny, revoke or suspend my application for a Lead Professional
passport size (2” x 2” exact size)
License for knowingly making false or fraudulent claims.
photograph with tape here.
The picture shall have the
printed name of the applicant on
Signature:
Date:
the reverse side of the photo.
Licenses will not be issued
Important Notice: This state agency is requesting disclosure of information that is necessary to accomplish the
without an identification
statutory purpose as outlined under public law PA 87-175. Disclosure of this information is mandatory. Failure
photograph.
to provide any information could result in denial, revocation or suspension of the applicant’s license.
This application shall be signed and dated. Application forms are processed in the order they are received. Walk-in applicants will have their applications
added to that day’s work and the licenses mailed to them. E-mailed and faxed applications will not be accepted. Please allow 4 weeks for the
Department to process the application and send the license in the mail. For additional information you may contact the Illinois Lead Program at
217-782-3517. Mail to: Illinois Department of Public Health, Division of Environmental Health, Illinois Lead Program, 525 W. Jefferson St., 3rd Floor,
Springfield, IL 62761.
IOCI 17-558
Application for Lead Worker Licensure and Renewal
Individual Licensing Requirements for Lead Activities – Illinois Lead Poisoning Prevention Code
Section 845.125
a) To conduct any lead services, including lead inspection, lead risk assessment, lead hazard screen, lead mitigation, and lead
abatement work and supervision, in a regulated facility in Illinois, an individual shall be licensed in accordance with the Act and
this Section. To qualify for a license as a lead inspector, lead risk assessor, lead supervisor, or lead worker, an applicant shall
meet the following requirements:
1) Be at least 18 years of age
2) Submit the IDPH-approved lead training course certificate
A) The training course completed shall be for the discipline for which licensure is sought.
B) Training course certificates are valid for three years from the date the applicant passed the approved lead training
course examination.
C) Training course certificates shall be renewed every three years by successfully completing an IDPH-approved refresher
training course in the appropriate discipline.
D) If four years have passed since the applicant passed the approved training course examination, the training course
certificate cannot be refreshed. An applicant is required to complete the initial lead training course as required by this
Section.
3) Submit a recent 2” x 2” photograph of the applicant for proper identification of the licensee; the picture shall have the
printed name of applicant on the reverse side and the license will not be issued without an identification photograph
4) Submit the appropriate completed application form provided by IDPH
5) Submit the required license application fee
6) For applicants seeking initial licensure as a lead inspector, lead risk assessor, and lead supervisor, the applicant must meet
the third party examination requirements of subsection (e) of this Section and Section 845.135 of this Part
b) Fees for Lead Licensure, Renewal, Late Renewals, and Reinstatement of Expired Licenses
1) Applicants for an initial lead license or renewal of an existing lead license shall pay an annual non-refundable fee as
specified below
A) Lead worker license − $50
B) Lead supervisor license − $100
C) Lead inspector license − $100
D) Lead risk assessor license − $100
2) In addition to the annual renewal license fee, an applicant shall pay a nonrefundable late fee of $25:
A) If a renewal application for a lead inspector or lead risk assessor license is received after January 1; or
B) If a renewal application for a lead worker or a lead supervisor license is received after March 1.
3) An applicant whose license has been expired for a period fewer than three years may apply to IDPH for reinstatement of
the license. IDPH shall issue a reinstated license provided that:
A) The applicant pays to IDPH the current license fee applicable to the discipline to be reinstated, in accordance with
subsection (b)(1); and
B) The applicant pays a non-refundable reinstatement fee based on the following:
i)
Lead workers: $25 for each year the license has expired; and
ii) Lead supervisors, inspectors and lead risk assessors: $50 for each year the license has expired.
4) A license that has been expired for more than three years may be restored only by submitting a new application in
accordance with subsection (a) of this Section.
c)
All lead licenses expire annually in accordance with the following:
IOCI 17-558
Application for Lead Worker Licensure and Renewal
1) Lead inspector and lead risk assessor licenses expire January 31 of each year, except that a first-time license issued after
October 31 and before January 31 shall expire the next following January 31; and
2) Lead worker and lead supervisor licenses expire March 31 of each year, except that a first-time license issued after
December 31 and before March 31 shall expire the next following March 31.
d) Renewal of License - Any license issued pursuant to this Part may be renewed if the licensee submits:
1) The completed renewal application
2) The non-refundable license renewal fee outlined in subsection (b)(1)
3) A recent 2” x 2” photograph of the applicant for proper identification of the licensee; the picture shall have the printed
name of the applicant on the reverse side and the license shall not be issued without an identification photograph
4) A current certificate of completion from an IDPH-approved training course in accordance with subsection (a)(2) of this Section
e) In addition to meeting the general requirements outlined in subsections (a) and (b) of this Section, lead inspector, lead risk
assessor and lead supervisor disciplines have specific training course requirements, examination and education and experience
requirements as specified in this subsection (e):
1) To qualify for a license as a lead risk assessor, a person shall:
A) Submit the training course completion certificates, including one of the two following combinations:
i)
An initial lead inspector training course certificate and any subsequent refresher certificates required to maintain
accreditation as outlined in subsection (a) of this Section, and an initial lead risk assessor training course
certificate, and any subsequent refresher certificates required to maintain accreditation as outlined in subsection
(a) of this Section; or
ii) An initial lead risk assessor training course certificate and any subsequent refresher certificates required to
maintain accreditation as outlined in subsection (a) of this Section, and a current Illinois lead inspector license.
B) Possess one of the following combinations of education and experience:
i)
A Bachelor of Science degree in engineering, environmental, or health-related field; or
ii) A bachelor's degree in any discipline and one year of experience in a related field (e.g., lead, asbestos or
environmental remediation work, or construction); or
iii) An associate's degree in any discipline and two years of experience in a related field (e.g., lead, asbestos or
environmental remediation work, or construction); or
iv) A high school diploma (or equivalent) and at least three years of experience in a related field (e.g., lead, asbestos
or environmental remediation work, or construction); or
v) Licensure as an industrial hygienist, professional engineer, architect, or environmental health practitioner; and
C) Pass IDPH’s third party examination for lead risk assessor as required by Section 845.135.
2) To qualify for a license as a lead inspector, a person shall:
A) Submit the training course completion certificates, including an initial lead inspector training course certificate and any
subsequent refresher certificates required to maintain accreditation as outlined in subsection (a) of this Section; and
B) Pass the IDPH’s third party examination for lead inspector as required by Section 845.135.
3) To qualify for a license as a lead supervisor, a person shall:
A) Submit the training course completion certificates, including an initial lead supervisor training course certificate and any
subsequent refresher certificates required to maintain accreditation as outlined in subsection (a) of this Section; and
B) Meet the experience requirements as follows:
i)
One year of experience as a certified lead-based paint abatement worker; or
ii) Two years of experience in a related field (e.g., lead, asbestos, or environmental remediation work) or in the
building trades.
C) Pass the IDPH’s third party examination for lead supervisor as required by Section 845.135.
IOCI 17-558

Download Form IOCI 17-558 Application for Lead Worker Licensure and Renewal - Illinois

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