OHC Certification and Recertification Course Approval Form

This form is due 15 days in advance of any course.

Instructions: All OHC Certification and Recertification courses must be registered through the CAOHC office. All sections must be completed before the application will be accepted for approval.

Part 1 - Course Director (CD) Information

CD Certification Number:

License Number:

State:

Expiration:

Course Director Name:

Company Name:

Address:

City:

State:

ZIP Code:

Phone:

Email:

Part 2 - Course Information

Step 1 - Type of Course

If this is a combined course please complete dates for certification and recertification course.

Note: If Certification and Recertification course dates are not concurrent, an additional course fee will apply.

Full Certification Course

Course Start Date:

Course End Date:

What date will you be holding the certification exam? What time will you be starting class that day?

Proposed Date *

Proposed Time *

Recertification Course**

Course Start Date:

Course End Date:

What date will you be holding the re-certification exam? What time will you be starting class that day?

Proposed Date *

Proposed Time *

Department of Defense/Military (DoD)*

Post this course to the CAOHC website, open to all applicants.

Do not post this course on the CAOHC website, it is a private course.

Cancellation Policy to be posted with the course listing:

Additional Notes for students when registering:

Step 2 - Course Location and Registration Information

Facility Name:

City:

State:

ZIP Code/Country Code:

How should participants register for the course?

Online

Website:

Contact CD

Phone:

or Email:

Contact other:

Name of contact:

Phone:

or Email:

*DoD course fees are centrally funded.
**If recertification course is separate from certification course dates a $50 fee applies.

Step 3 - Faculty

Each 20-hour course must include faculty members from at least three different disciplines represented on the Council, and must follow the CAOHC Course Outline for content and time allotments. Supplemental OHC course faculty, other than the Course Director, must be actively engaged in their profession. Supplemental instructors do not have to be certified by their professional organization.

Disciplines, and suitable terminology describing them, are:

Audiology (Audiologist, Occupational Audiologist, Military Audiologist, Industrial Audiologist, Certified Audiologist)
Occupational health nursing (Occupational Health Nurse, Industrial Nurse, Registered Nurse)
Safety (Safety Engineer, Safety Professional)
Industrial hygiene (Industrial Hygienist, Certified Industrial Hygienist)
Occupational medicine (Occupational Physician, Occupational and Environmental Physician, Physician)
Otolaryngology (Otolaryngologist, Otologist, ENT Physician, ENT/Head and Neck Surgeon)
Noise control engineering (Noise Control Engineer, Acoustical Engineer). In lieu of one required professional discipline instructor, CAOHC authorized video/DVD curriculum package may be substituted. Video/DVD curriculum substitution is allowed per approved course, and must be indicated below.

Note: If the CD is not an audiologist it is strongly recommended that an audiologist be present for audiometry instruction and the audiometric practicum.

Faculty 1

Course Director (self)

Faculty 2

Name:

Degree Designation:

(e.g. Video, MD, PhD, COHN, etc.)

Discipline:

Phone:

Faculty 3

Name:

Degree Designation:

(e.g. Video, MD, PhD, COHN, etc.)

Discipline:

Phone:

Faculty 4

Name:

Degree Designation:

(e.g. Video, MD, PhD, COHN, etc.)

Discipline:

Phone:

Faculty 5

Name:

Degree Designation:

(e.g. Video, MD, PhD, COHN, etc.)

Discipline:

Phone:

Additional faculty/and/or instructors:

Step 4 - Course Outline

AUDIOMETRIC PRACTICUM must be a MINIMUM of 150 minutes (2.5 hours) for the 20-hour course and 60 minutes for the 8-hour course.

HEARING PROTECTION PRACTICUM must be a MINIMUM of 60 minutes for the 20-hour course and 30 minutes for the 8-hour course.

COURSE CURRICULUM INSTRUCTION
There are no mandatory times assigned to the instruction of the 11 exam domains. Suggested times are provided and encouraged but individual CDs may adjust the schedule according to their needs.

CERTIFICATION COURSES must include a MINIMUM of 20 hours instruction including all required practicum and examination time.

RECERTIFICATION COURSES must include a MINIMUM of eight(8) hours of instruction including all required practicum and examination time.

Course Directors can distribute instruction and practicum hours however they choose. However, CAOHC, strongly recommends limiting instruction time to 8 hours per day, as it may causes a strain on the attention and comprehension of the students, and strain on the instructors as well.

Part 3 - Attestation

Course Director makes the following representations, warranties and covenants and understands that CAOHC reserves the right to withdraw approval for failure to abide by these requirements:

I verify that the information provided in this Course Approval application is true and correct and is not false or misleading in any respect.

I verify that my license (or the equivalent) is current.

As a Course Director I will abide by all rules, regulations, guidelines, procedures and polices of CAOHC regarding OHC certification and recertification courses, as amended from time to time.

I verify that this course, if approved by CAOHC, will adhere to the information I have provided in this application, and that I will be physically present and readily accessible throughout the course(s).

I verify that I will administer both the audiometric and hearing protection practicum as required by CAOHC.

Check one of the following options:

I verify that I will administer the OHC standardized certification or recertification exam in compliance with the policies and procedures established.

For DoD courses: I verify that if I choose not to administer the CAOHC standardized exam, I will administer a final exam that is in compliance with CAOHC policies for both Certification and Recertification courses. Questions for the exam(s) will come from the CAOHC exam bank.

Part 4 - Payment

OHC Certification and Recertification course fees are $50.00 per course. Note if you cancel a course the $50.00 fee is non-refundable. DoD courses do not require a course fee.

You may submit your course fee using VISA, MasterCard, AMEX, or Discover. Please contact the CAOHC office with any questions by emailing info@caohc.org.

Total Amount Due:

This section will calculate the amount due based on the number of courses submitted using the form. If Certification and Recertification course dates are not concurrent, an additional course fee will apply.

Card Type:*

MasterCard

Visa

American Express

Name on Card:*

Credit Card Number:*

Expiration Date (MM/YY):*

(You may begin a request for an additional course on the next page.
Your Part 1 information will be carried over.)

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