CWA Work-At-Height Qualified Person Certification Programapplication

CWA Work-at-Height Qualified Person Certification ProgramApplication

Instructions for contact information:Please provide the following information – all fields are required.

Name:

Name of Employer/Company:

Position/Title:

Company Address:

Personal Address (required):

Work Phone: Work Email:

Mobile Phone: Personal E-Mail:

Instructions for prerequisites and additional questions:Please check all that apply, or provide brief answers to the following questions. This application is intended to provide your instructor with sufficient information to make an informed decision regarding your candidacy for certification and your readiness for the training and evaluation.

Prerequisites:

1)I am 18 years of age or will be by the conclusion of the course. ☐Yes ☐No

2)I can demonstrate basic climbing skills. ☐Yes ☐No

3)I have, or am provided with, appropriate equipment in good condition.☐Yes ☐No

4)I can demonstrate proper care, use and inspection of climbing equipment.☐Yes ☐No

5)I can demonstrate proficient belay technique.☐Yes ☐No

6)I can lead climb 5.9 on artificial terrain. ☐Yes ☐No

7)I can ascend a rope.☐Yes ☐No

8)I have reviewed the regulatory requirements in the jurisdiction in which I work.☐Yes ☐No

9)I have the ability to successfully complete the assessment of skills for this course.☐Yes ☐No

Additional Questions:

10)How many years of personal climbing experience do you have?

11)How many hours of climbing or work-at-height training have you received in the last three years?

12)How many hours of on-the-job work-at-height experience have you had the last year?

13)Describe your ongoing professional development activities and continuing education efforts.

14)Have you ever conducted a written hazard assessment for your company or employer? If so, when?

15)Have you ever written a hazard protection or fall protection plan for your company or employer? If so, when?

16)Have you completed PPE Qualified Person training in the last three years? If not, what kind of training have you received in the selection, care, use and inspection of PPE in the last three years?

17)Describe the access methods that you are familiar with based upon your training or work experience.

18)Describe the rescue techniques that you are familiar with based upon your training or work experience.

19)Do you hold anylicenses, certifications, other credentials that might be relevant to your application?

20)Briefly describe any other experience or areas of expertiseyou may have that might be relevant.

21)Please provide the name, contact information and daytime phone number fortwo non-related references:

22)Are you willing to attend ongoing professional development training to maintain your CWA certification?

23)Are you interested in receiving information about becoming a certification provider?

Please send a copy of your completedapplication to:Dan Jeanette

Climbing Wall Association, Inc.

1460 Lee Hill Rd., Unit 7

Boulder, CO 80304

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