CANDIDATE HANDBOOK, PROGRAM OUTLINE, AND APPLICATION

Transcription

1 ASSE 6040 MEDICAL GAS SYSTEMS MAINTENANCE PERSONNEL CERTIFICATION PROGRAM CANDIDATE HANDBOOK, PROGRAM OUTLINE, AND APPLICATION CREATED BY JONATHAN C. WILLARD ASSE 6050 & 6055 CERTIFIED INSTRUCTOR TRAINING PROVIDER MEDICAL GAS CERTIFICATIONS, INC. NEW BOSTON, NEW HAMPSHIRE OUR MISSION IS TO PROVIDE THE MOST COMPREHENSIVE, ACCESSIBLE, AND COST EFFECTIVE MEDICAL GAS TRAINING IN THE HEALTHCARE INDUSTRY ASSE 6000 MEDICAL GAS CERTIFICATION PROGRAMS ONLINE

2 CANDIDATE HANDBOOK, PROGRAM OUTLINE, AND APPLICATION 2 Table of Contents SECTION 1: CERTIFICATION PROGRAM OVERVIEW CERTIFICATION INFORMATION CERTIFICATION / ELIGIBILITY REQUIREMENTS PROGRAM FEES ABOUT THE INSTRUCTOR ABOUT THE TRAINING PROVIDER (MEDICAL GAS CERTIFICATIONS, INC.) ABOUT THE EXAM ADMINISTRATOR AND TESTING AGENCY (MGI SYSTEMS, INC) ABOUT THE PROGRAM ADMINISTRATOR (MEDICAL GAS TRAINING INSTITUTE) RENEWAL OF CERTIFICATION REQUIRED COURSE MATERIALS... 5 SECTION 2: APPLICATION PROCEDURES GENERAL ADHERENCE TO THE PROFESSIONAL STANDARDS OF CONDUCT PROFESSIONAL STANDARDS OF CONDUCT... 5 SECTION 3: FINAL EXAMINATION PROCEDURES GENERAL FINAL EXAMINATION PRIOR TO TAKING THE FINAL EXAMINATION TAKING THE FINAL EXAMINATION FINAL EXAMINATION SCORING & SCORE REPORTS REEXAMINATION... 9 SECTION 4: PENALTIES / REFUND POLICIES GENERAL... 9 PROGRAM OUTLINE PROGRAM APPLICATION FORM FINAL EXAM REGISTRATION FORM FINAL EXAM IDENTITY AFFIDAVIT QUESTION CHALLENGE FORM CERTIFICATION CHECKLIST & PHOTOGRAPH GUIDELINES EXAM ADMINISTRATOR: PROGRAM ADMINISTRATOR: MGI Systems, Inc. Medical Gas Training Institute PO Box Bedford Road Orlando, FL New Boston, NH Phone: Phone: Fax: Fax: dan.chisholm.jr@mgisys.com jwillard@medgasinstitute.com

3 CANDIDATE HANDBOOK, PROGRAM OUTLINE, AND APPLICATION 3 CANDIDATE HANDBOOK ASSE 6040 MAINTENANCE PERSONNEL PROGRAM SECTION 1: CERTIFICATION PROGRAM OVERVIEW 1.01 Certification Information The ASSE 6040 Medical Gas Systems Maintenance Personnel Certification Program was developed to provide qualified individuals, who are responsible for the proper inspection, testing, and maintenance of medical gas and vacuum systems, with the certification necessary to ensure that the individual has met the requirements of the ASSE Series 6000 Professional Qualifications Standard and are technically competent and experienced in the field of medical gas systems inspection, testing, and maintenance. The program is based on the code requirements identified in the NFPA 99: Health Care Facilities Code, current edition. Candidates will also be given a basic understanding of medical gas systems general knowledge, applications, component overview, basic operating principles and performance characteristics, critical safety precautions, troubleshooting, routine maintenance and testing, and common repairs. This program was developed by an ASSE 6050 and ASSE 6055 Certified Instructor. It is web based and selfpaced, and the training modules and program content are all provided online. The program is comprised of a verification of work experience prerequisites, a 32-hour training course, and a final examination. This program offers the convenience and flexibility that makes the ASSE 6040 Maintenance Personnel Certification accessible and achievable. The training program can be accessed via the web at any location where a computer with Internet access is available Certification / Eligibility Requirements The Medical Gas Systems Maintenance Personnel Certification is administered in accordance with the American Society of Sanitary Engineers (ASSE) Series 6000 Standard, Section Candidates must meet the following requirements in order to become ASSE 6040 Certified. A. All candidates shall be employed or contracted by a healthcare facility or actively engaged in working with medical gas systems. B. All candidates shall have a minimum of one (1) year of documented experience in the inspection, testing, or maintenance of medical gas systems. C. All candidates shall have successfully completed the thirty-two (32) hour training course covering all aspects of the ASSE Standard D. All candidates must successfully pass the final examination Program Fees The Program Fee is $ Once eligibility has been confirmed and acceptance into the program has been granted, a candidate must submit the program fee. The program fee must be received prior to starting the program. The program fee covers the following items. A. (32) Hour online training course B. Final Examination C. Access to program author for questions and clarifications D. Completion Wall Certificate & Certification Card

4 CANDIDATE HANDBOOK, PROGRAM OUTLINE, AND APPLICATION About the Instructor The program was developed by Mr. Jonathan C. Willard, who is an ASSE 6050 and 6055 Certified Instructor, and has worked in the medical gas and construction industry for over 16 years. Mr. Willard is the president and owner of Certified Medical Gas Services (CMGS), which is a comprehensive medical gas services provider. In addition to holding the following medical gas credentials, Mr. Willard is a principal member of the Technical Committee on Medical Gas and Vacuum Piping Systems (NFPA 99: Health Care Facilities Code) and a principal member of the Technical Committee on Industrial and Medical Gases (NFPA 55: Compressed Gases and Cryogenic Fluids Code). He is also a LEED AP (Accredited Professional), a certified Project Management Professional (PMP ), and a Certified Healthcare Constructor (CHC ) with a Master of Science degree in Business Education (MBE). Medical Gas Credentials: ASSE 6010 Medical Gas Systems Installer Certified ASSE 6015 Bulk Medical Gas Systems Installer Certified ASSE 6020 Medical Gas Systems Inspector Certified ASSE 6030 Medical Gas Systems Verifier Certified ASSE 6040 Medical Gas Systems Maintenance Personnel Certified ASSE 6050 Medical Gas Systems Instructor Certified ASSE 6055 Bulk Medical Gas Systems Instructor Certified MGPHO Credentialed Medical Gas Verifier (V-0135) Mr. Willard is listed on the Medical Gas Professional Healthcare Organization (MGPHO) website as an ASSE 6050 instructor. Copyrighted Program Materials All program materials are the copyrighted property of Mr. Jonathan Willard and the Medical Gas Training Institute. It is forbidden under federal copyright law to copy, reproduce, record, distribute, or display these materials by any means, in whole or in part. Doing so may result in severe civil and criminal penalties About the Training Provider (Medical Gas Certifications, Inc.) Medical Gas Certifications, Inc. (MGC), a company founded to provide quality, self-paced, affordable online training for medical gas systems. The training is conducted in a webinar format and is accessed via the Internet at the MGC website About the Exam Administrator and Testing Agency (MGI Systems, Inc.) MGI Systems, Inc. (MGI) was founded in 1995 as an educational company focused on providing training and certifications for health care facilities. MGI is focused on providing E-learning courses dedicated to the utility systems found in healthcare facilities all over the country About the Program Administrator (Medical Gas Training Institute) The program is administered by the Medical Gas Training Institute (MGTI). Other than the training and final examinations, CMGS is the administrator for all aspects of the program. The Medical Gas Training Institute will issue completion certificates and certification cards Renewal of Certification Attaining certification is an indication of mastery of a well-defined body of knowledge at a point in time. Periodic renewal of the certification is required to maintain certified status. Initial ASSE 6040 certification or renewal of certification is valid for three (3) years.

5 CANDIDATE HANDBOOK, PROGRAM OUTLINE, AND APPLICATION 5 Candidates who successfully complete the examination are provided information about certification renewal requirements in the certification package sent by the Medical Gas Training Institute. A copy of the ASSE 6040 Renewal Application is also available at The renewal application must be submitted 30 days prior to expiration date as listed on the wall certificate and certification card. Certificate holders will receive multiple s notices of pending expiration from MGC. Certificate holders are responsible for keeping their certifications current and up to date. To ensure receipt of communications, it is suggested that certificate holders keep their contact information current. MGTI and MGC are not responsible for communications not received due to incorrect contact information in a certificate holders record. Certificate holders may renew their certification by meeting the following requirements: A. Completion of current ASSE 6040 Certification Renewal Application B. Completion of a (4) hour recertification training course offered by Medical Gas Certifications, Inc. C. Successful completion of the certification renewal exam For current ASSE 6040 Certification Renewal Application and fees, please visit the Medical Gas Certifications, Inc. website ( Failing to Renew A certificate holder that fails to renew his/her certification is no longer considered certified and may not use the ASSE 6040 credential in professional communications, such as letterhead, stationary, and business cards, in directory listings, and in signatures. To regain certification, the individual must retake and pass the ASSE 6040 Examination (subject to the usual fees and provisions for testing) Required Course Materials Candidates eligible for the ASSE 6040 program must attain a copy of NFPA 99: Health Care Facilities Code, current edition. This text will be referred to during the training modules and will be required for completing the program. In addition to these texts, it is recommended that the following documents be attained as well, but are not required. A. ASSE Standard Series 6000: Professional Qualifications Standard for Medical Gas Systems Personnel B. CGA M-1: Guide for Medical Gas Supply Systems at Consumer Sites C. CGA E-10: Maintenance of Medical Gas and Vacuum Systems in Healthcare Facilities SECTION 2: APPLICATION PROCEDURES 2.01 General Candidates must complete the Program Application in this handbook and fax to Medical Gas Certifications, Inc. at (888) prior to entering into the ASSE 6040 Certification Program. In addition to information that verifies eligibility, the application contains a Professional Standard of Conduct. These standards must be adhered to in order to remain a certificate holder. Once the application process has been completed, the Candidate Training Manual will be issued, and the candidate may begin the program and access all the program content online Adherence to the Professional Standards of Conduct Medical Gas Certifications, Inc. is responsible to its candidates, certificate holders, employers, the profession, regulatory agencies, and the public for ensuring integrity of all its processes and products of its Certification Programs. As such, MGC requires adherence to these Professional Standards of Conduct by all who have achieved acceptance into the ASSE 6040 Certification Program and/or attained the ASSE 6040 Certification. A candidate must agree on the application to accept and adhere to the Professional Standards of Conduct.

6 CANDIDATE HANDBOOK, PROGRAM OUTLINE, AND APPLICATION Professional Standards of Conduct A candidate, who has been accepted into the program and/or an ASSE 6040 Certificate Holder by the Medical Gas Training Institute, agrees to conduct himself/herself in an ethical and professional manner. This includes demonstrating practice-related behavior that is indicative of professional integrity. By acceptance into the program and/or issuance of certificate, the candidate or certificate holder agrees to the following: A. Maintain professional competence B. Demonstrate work behavior that exemplifies ability to perform safely, competently, and with good judgment C. Conduct activities with honesty and integrity D. Avoid discriminating against any individual based on age, gender, race, color, religion, national origin, disability, or marital status E. Avoid conflicts of interest F. Abide by laws, rules, and regulations of duly authorized agencies regulating the industry G. Abide by rules and regulations governing programs conducted by MGTI Infraction of the Professional Standards of Conduct An infraction is misconduct for which acceptance into the program, granting of certification, or renewal of certification may be delayed or denied, or for which acceptance in the program or a certification may be revoked by the Medical Gas Training Institute. Reporting Violations To protect the national credentials and to ensure responsible practices by its candidates and certificate holders, the Medical Gas Training Institute depends upon its candidates, certificate holders, employers, the profession, regulatory agencies, and the public to report incidents that may be in violation of these Professional Standards of Conduct. A certificate holder who has violated these Standards should voluntarily surrender his/her certification. Written reports of infraction of these Standards may be sent to: President, Medical Gas Training Institute, 532 Bedford Road, New Boston, NH Only signed, written communication will be considered. The Medical Gas Training Institute will become involved only in matters that can be factually determined, and commits to handling any situation as fairly and expeditiously as possible. During its investigation and decision, MGTI will protect the confidentiality of those who provide information to every possible extent. The named individual will be afforded every opportunity to respond in a professional and legally defensible manner, in accordance with policies and procedures established by MGTI. SECTION 3: FINAL EXAMINATION PROCEDURES 3.01 General Upon completion of the (32) hour training program, the candidate may register to complete the final examination. The final examinations are administered by MGI Systems, Inc. through the MGC website. All scoring reports will be forwarded to the Medical Gas Training Institute. If the candidate is successful in passing the final examination, wall certificates and certification cards will be sent via mail to the newly certified individual Final Examination The final examination is based on the content reviewed during the (32) hour training program. It includes content from NFPA 99: Health Care Facilities Code, current edition, NFPA 55: Compressed Gases and Cryogenic Fluids Code, current edition, ASSE Series 6000 Professional Qualification Standard, and many other generally accepted industry documents, policies, and procedures that are discussed throughout the program. An outline of the program can be found below.

7 CANDIDATE HANDBOOK, PROGRAM OUTLINE, AND APPLICATION 7 ASSE 6040 Medical Gas Systems Maintenance Personnel Certification A. Code and Standard Review Final Examination Content Outline B. Patient, Public, and Personnel Safety Guidelines C. Basic Concepts, Terminology, and Definitions D. Medical Gas Systems Qualifications E. The Purposes and Uses of Medical Gases F. Medical Gas Cylinder and Container Best Practices G. Medical Gas Headers and Manifold Systems H. Medical Grade Bulk Oxygen Systems I. Medical Air Supply Systems J. Medical Surgical Vacuum Pump Systems K. Waste Anesthesia Gas Disposal (WAGD) Pump Systems L. Instrument Air Compressor Supply Systems M. Medical Gas Control Valves and Zone Valve Boxes N. Medical Gas Station Outlets and Inlets O. Medical Gas Alarm Warning Systems P. Medical Gas Pipeline Distribution Systems Q. Medical Gas Systems Performance Criteria and Testing R. Category 2 and Category 3 Medical Gas and Vacuum Systems S. Medical Gas Systems Operation and Management Programs T. Medical Gas Systems Policies and Procedures U. Medical Gas Systems Inspection and Testing Equipment V. Medical Gas Equipment Maintenance, Troubleshooting, and Repairs W. Medical Gas Systems Design Resource Overview X. Medical Gas Systems Inspection and Testing Procedures Y. NFPA 99B: Standard for Hyperbaric Facilities

8 CANDIDATE HANDBOOK, PROGRAM OUTLINE, AND APPLICATION Prior to taking the Final Examination Prior to taking the final examination, candidates must complete the following: A. (32) Hour online training course B. Final Examination Review C. Final Exam Registration Eligibility A representative of the Medical Gas Training Institute, will determine eligibility for the final examination. Once all items identified above are completed, a representative will review for approval. Once approved, the candidate will be notified and the final examination will become available. If it is determined that not all requirements have been met, the candidate will be notified and informed as to what items still need to be completed. Examination Registration Prior to taking the final examination, the Final Exam Registration must be completed and faxed to (888) for review. This is to ensure that all requirements have been met Taking the Final Examination The final examination is a timed closed book online assessment that is made up of (100) multiple choice and true/false questions. Candidates are allowed two (2) hours to complete the examination. Once the examination begins, the candidate is provided a short tutorial on using the software to take the examination. Once the final examination has begun, you will not be able to stop the exam. You must complete the entire exam. If you do not finish the exam once it has begun, all unanswered questions will be marked incorrect. If you fail the exam, you will then need to go through the re-examination process in order to re-take the exam. Time will be monitored on the examination software and is indicated on the screen by a digital clock. The examination will terminate after the allowed two (2) hour mark. When the examination has been completed, candidates will receive the results of the exam and the program will indicate whether or not they passed the exam. Identification of Candidates and Final Examination Affidavit All candidates are required to complete the candidate portion of the Final Exam Identity Affidavit. This document is to ensure that the candidate completing the exam is the person registered to do so. A facility director, department manager, education program manager, or organization executive must sign this affidavit just prior to taking the final examination. The Final Exam Identity Affidavit must be faxed to (888) once the final exam has been completed. Candidates must send a digital photograph of themselves to 6040photo@medgascerts.com or upload a digital photograph to the website at after passing the final examination. The guidelines for the candidate photo can be found on the Certification Checklist at the end of this document. Copyrighted Final Examination Questions All examination questions are the copyrighted property of the Medical Gas Training Institute. It is forbidden under federal copyright law to copy, reproduce, record, distribute, or display these examination questions by any means, in whole or in part. Doing so may result in severe civil and criminal penalties.

9 CANDIDATE HANDBOOK, PROGRAM OUTLINE, AND APPLICATION Final Examination Scoring Candidates will receive his/her score once the final examination has ended. The score will also indicate a Pass or Fail, which is determined by the percentage of questions answered correctly. Candidates must answer (75%) or more of the questions correctly in order to achieve a passing grade. Request for Review of Questions A candidate may challenge, at the conclusion of the examination, any question(s) by completing the question challenge form that is provided in this handbook. Candidates must request a review of any question(s) within one week of completing the final examination. Final Examination Appeals Candidates may appeal the score of a final examination. Appeals shall be filed in writing to the Medical Gas Training Institute office via U.S. Mail, facsimile, or electronic mail no later than thirty (30) days from the date candidate receives the score. Appellants will be notified in writing of the decision by the organization. The complete appeals procedure can be obtained from the organization upon request. Passing Final Examination A candidate who passes the final examination is awarded the ASSE 6040 Medical Gas Systems Maintenance Personnel Certification credential. In recognition of this accomplishment, the candidate will receive a certification package in the mail within (14) business days. The certification package will include a wall Certificate of Accomplishment, Certification Card, and a Sample News Release for their use Re-Examination Candidates who have failed the final examination must wait ten (10) days from the last examination date to take the re-examination. The candidate will also be required to complete the Final Exam Registration and the Final Exam Identity Affidavit again. It is also recommended that the candidate retake the Final Examination Review as well. The first re-examination is complimentary, but there will be a fee of $ for any additional re-examinations after the first one. SECTION 4: PENALTIES / REFUND POLICIES 4.01 General The program fee covers the (32) hour online training course, one (1) final examination attempt, (1) final reexamination (if required), reasonable access to program author for questions and clarifications, a wall completion certificate (once certified), and a certification card (once certified). It does not cover any costs associated with the second re-examination if required. Candidates have one (1) year from the date they begin the program to complete all the requirements and take the final examination. Failure to complete these requirements and pass the final examination within one (1) year will result in forfeit of program fees. No refunds will be granted once you have started the online training portion of the program. All other refund requests must be submitted in writing. Written requests may be sent to: Medical Gas Certifications, Inc., 532 Bedford Road, New Boston, NH or ed to jwillard@medgascerts.com. Only written requests prior to the start of the online training program will be considered.

10 CANDIDATE HANDBOOK, PROGRAM OUTLINE, AND APPLICATION 10 PROGRAM OUTLINE ASSE 6040 MAINTENANCE PERSONNEL PROGRAM SECTION 1: CERTIFICATION PROGRAM 1.01 Summary The main focus of the ASSE 6040 Medical Gas Systems Maintenance Personnel Course is to provide individuals, who are responsible for the proper inspection, testing, and maintenance of medical gas systems, with the requirements necessary to maintain, inspect, and test Category 1, 2, & 3 medical gas and vacuum systems installed at healthcare facilities. The current edition of NFPA 99 is used to provide all code requirements discussed within this course and other various codes and standards are used to supplement the information presented. Attendees will also be given a basic understanding of the application, operation, and code requirements of all materials, components, and equipment that are used in medical gas systems. This course provides details on the materials, components, and equipment utilized in medical gas systems and guidance on standardized maintenance and testing techniques used on these systems. There will be a written exam to assess candidates understanding of the materials covered in the course Prerequisites Candidates must be employed or contracted by a healthcare facility or actively engaged in working with medical gas systems and must have a minimum of one (1) year of documented experience in the maintenance and/or testing of medical gas systems Program Outline A. Course Introduction 1.) Purpose of the course 2.) Course Overview 3.) Program Outline 4.) Instructor Information B. Code and Standard Review 1.) Applicable Codes & Standards a.) NFPA 99, current edition b.) ASSE Series 6000, current edition c.) NFPA 55, current edition d.) Joint Commission e.) Centers for Medicare and Medicaid f.) Federal Regulations g.) Compressed Gas Association 2.) Healthcare System Category Requirements C. Patient, Personal, and Public Safety 1.) Nature of Hazards 2.) Personal Protective Equipment a.) Eye Protection b.) Ear Protection c.) Hand Protection d.) Protective Footwear e.) Lockout/Tag-out

11 CANDIDATE HANDBOOK, PROGRAM OUTLINE, AND APPLICATION 11 D. Basic Concepts, Terminology, & Definitions 1.) NFPA 99 Terms and Definitions 2.) Source Equipment Basics E. Medical Gas System Qualifications 1.) ASSE 6000 Series Qualifications 2.) MGPHO Credentialed Medical Gas Verifier F. The Purposes and Uses of Medical Gases 1.) Properties, Uses, and Basic Information G. Medical Gas Cylinder and Container Best Practices 1.) Storage & Ventilation Requirements 2.) General Safety Practices 3.) Container Security H. Medical Gas Headers & Manifold Systems 1.) Application & Components 2.) Basic Operating Principles & Performance Characteristics 3.) NFPA 99 Requirements 4.) Critical Safety Precautions I. Bulk Oxygen Systems 1.) Application & Components 2.) Basic Operating Principles & Performance Characteristics 3.) NFPA 99 Requirements 4.) Critical Safety Precautions J. Medical Air Systems 1.) Application & Components 2.) Basic Operating Principles & Performance Characteristics 3.) NFPA 99 Requirements 4.) Critical Safety Precautions K. Medical Surgical Vacuum Systems 1.) Application & Components 2.) Basic Operating Principles & Performance Characteristics 3.) NFPA 99 Requirements 4.) Critical Safety Precautions L. Waste Anesthesia Gas Disposal (WAGD) System 1.) Application & Components 2.) Basic Operating Principles & Performance Characteristics 3.) NFPA 99 Requirements 4.) Critical Safety Precautions M. Instrument Air Systems 1.) Application & Components 2.) Basic Operating Principles & Performance Characteristics 3.) NFPA 99 Requirements 4.) Critical Safety Precautions

12 CANDIDATE HANDBOOK, PROGRAM OUTLINE, AND APPLICATION 12 N. Valves 1.) Application & Components a.) Source Valves b.) Mainline Valves c.) Emergency Oxygen Supply Connection (EOSC) Valves d.) Riser Valves e.) Zone Valves f.) Service Valves g.) In-Line Valves h.) Future Use Valves i.) Other Valve Types 2.) Basic Operating Principles 3.) Design Characteristics 4.) NFPA 99 Requirements O. Station Outlets and Inlets 1.) Application & Components a.) D.I.S.S. (Diameter Index) b.) Chemetron Style (Latch Type) c.) Diamond Style (Pin Index) d.) Puritan Bennett Style (Geometric) e.) Schrader (Quick Disconnect) 2.) Basic Operating Principles 3.) Design Characteristics 4.) NFPA 99 Requirements 5.) Critical Safety Precautions P. Alarm Warning Systems 1.) Application & Components a.) Master Alarms b.) Area Alarms c.) Local Alarms 2.) Basic Operating Principles 3.) Design Characteristics 4.) NFPA 99 Requirements 5.) Critical Safety Precautions Q. Category 1 Medical Gas Pipeline Distribution System 1.) Piping Material Requirements 2.) Joining Methods 3.) System Installation R. System Performance Criteria & Testing 1.) NFPA 99 Requirements for Testing, Inspections, and System Verifications S. Category 2 and Category 3 Medical Gas and Vacuum Systems 1.) NFPA 99 Requirements T. Operation and Management Programs U. Policies and Procedures 1.) Planned System Shutdown and Back-Feed Procedures 2.) Emergency Operations & Contingency Planning

13 CANDIDATE HANDBOOK, PROGRAM OUTLINE, AND APPLICATION 13 V. Inspection and Testing Equipment 1.) Inspection and Testing Equipment Requirements 2.) Technical Specifications 3.) Basic Operation W. Maintenance, Troubleshooting, & Repairs 1.) Routine Maintenance Guidelines 2.) Troubleshooting Techniques 3.) Minor Repairs X. System Design Resources Overview Y. Testing Procedures 1.) Standardized Inspection, Testing, and Performance Verification Requirements and Procedures Z. Hypobaric Facilities 1.) Terms and Definitions, Administration, Construction, and Maintenance AA. Final Examination Review BB. Final Examination 1.04 Instructor Mr. Jonathan C. Willard, who is an ASSE 6050 and 6055 Certified Instructor, has worked in the medical gas and construction industry for over 16 years. Mr. Willard is the president and owner of Certified Medical Gas Services, which is a comprehensive medical gas services provider. In addition to holding the following medical gas credentials, Mr. Willard is a principal member of the Technical Committee on Medical Gas and Vacuum Piping Systems (NFPA 99: Health Care Facilities Code) and a principal member of the Technical Committee on Industrial and Medical Gases (NFPA 55: Compressed Gases and Cryogenic Fluids Code). He is also a LEED AP (Accredited Professional), a certified Project Management Professional (PMP ), and a Certified Healthcare Constructor (CHC ) with a Master of Science degree in Business Education (MBE). Medical Gas Credentials: ASSE 6010 Medical Gas Systems Installer Certified ASSE 6015 Bulk Medical Gas Systems Installer Certified ASSE 6020 Medical Gas Systems Inspector Certified ASSE 6030 Medical Gas Systems Verifier Certified ASSE 6040 Medical Gas Systems Maintenance Personnel Certified ASSE 6050 Medical Gas Systems Instructor Certified ASSE 6055 Bulk Medical Gas Systems Instructor Certified MGPHO Credentialed Medical Gas Verifier (V-0135)

14 CANDIDATE HANDBOOK, PROGRAM OUTLINE, AND APPLICATION 14 NAME OF APPLICANT: MAILING ADDRESS: PROGRAM APPLICATION MAJOR MEDICAL ASSE 6040 MAINTENANCE PERSONNEL PROGRAM Candidate Information (Please Print) CITY: STATE: ZIP: HOME PHONE: CELL PHONE: ADDRESS: *SOCIAL SECURITY NO.: - *Social security number used for certification number only. (Last 6 Digits Only) EMPLOYER: Employment Information (Please Print) ADDRESS: CITY: STATE: ZIP: WORK PHONE: DATE EMPLOYMENT STARTED: Check ALL Boxes: Prerequisite Verification I am currently employed or contracted by a healthcare facility or actively engaged in working with medical gas systems. I have a minimum of one (1) year of documented experience in the maintenance or testing of medical gas systems. Statement of Eligibility: I do solemnly swear and affirm that the information provided above is true. I further realize that providing false information shall be just cause for disqualification from the program. By affixing my signature to this application, I agree to abide by the program rules and requirements set forth above, and as a holder of a Medical Gas Training Institute certification, I agree to not make any false claims about the scope of my certification(s). I understand that MGTI reserves the right to suspend or revoke my certification should I violate these obligations. Should my certification be revoked, I agree to cease and desist any and all references to being the holder of a MGTI certification and shall return any certificates, including wallet-sized photo identification cards, to MGTI. I also agree to not utilize any written documents, reports, procedures, etc, with the MGTI certification mark in any manner whatsoever that may be inaccurate. NAME (PLEASE PRINT): SIGNATURE: DATE: PLEASE FAX COMPLETED PROGRAM APPLICATION FORMS TO (888)

15 CANDIDATE HANDBOOK, PROGRAM OUTLINE, AND APPLICATION 15 FINAL EXAM REGISTRATION ASSE 6040 MAINTENANCE PERSONNEL PROGRAM NAME OF APPLICANT: MAILING ADDRESS: Candidate Information (Please Print) CITY: STATE: ZIP: HOME PHONE: CELL PHONE: ADDRESS: *SOCIAL SECURITY NO.: - *Social security number used for certification number only. (Last 6 Digits Only) NOTE: This is the address that all certificates and certification cards will be sent to. Check ALL Boxes: Eligibility Verification I am currently employed or contracted by a healthcare facility or actively engaged in working with medical gas systems. I have a minimum of one (1) year of documented experience in the maintenance or testing of medical gas systems. I have completed the (32) hour online training course on the Medical Gas Certifications, Inc. website. I have a copy of the required Final Exam Identity Affidavit that I will have with me at the final exam. Statement of Eligibility: I do solemnly swear and affirm that the information provided above is true. I further realize that providing false information shall be just cause for disqualification from the program. By affixing my signature to this application, I agree to abide by the program rules and requirements set forth above, and as a holder of a Medical Gas Training Institute certification, I agree to not make any false claims about the scope of my certification(s). I understand that MGTI reserves the right to suspend or revoke my certification should I violate these obligations. Should my certification be revoked, I agree to cease and desist any and all references to being the holder of a MGTI certification and shall return any certificates, including wallet-sized photo identification cards, to MGTI. I also agree to not utilize any written documents, reports, procedures, etc, with the MGTI certification mark in any manner whatsoever that may be inaccurate. NAME (PLEASE PRINT): SIGNATURE: DATE: PLEASE FAX COMPLETED FINAL EXAM REGISTRATION FORMS TO (888)

16 CANDIDATE HANDBOOK, PROGRAM OUTLINE, AND APPLICATION 16 FINAL EXAM IDENTITY AFFIDAVIT ASSE 6040 MAINTENANCE PERSONNEL PROGRAM This affidavit is used to authenticate your identity and verify that the candidate taking the final examination is the one listed below. This is a legal document and will require the signature of a facility director, department manager, education program manager, or an organization executive just prior to taking the final examination. NAME OF CANDIDATE: Candidate Information (Please Print) PREFERRED PHONE: TEST DATE: ADDRESS: *SOCIAL SECURITY NO.: - *Social security number used for certification number only. (Last 6 Digits Only) Identity Verification A facility director, department manager, education program manager, or an organization executive must complete this section just prior to taking the final examination. The completion of this form shall be witnessed. Check ALL Boxes: The candidate taking the final examination is the one listed above. The candidate presented a valid driver s license or other acceptable photographic identification. The candidate completed the final examination without the use of ANY course materials. Statement of Attest: I swear and affirm under penalty of perjury that the facts stated in this affidavit are true, correct, and complete to the best of my ability, belief, and knowledge. NAME OF VERIFIER (PLEASE PRINT): DATE: SIGNATURE OF VERIFIER: TITLE: Statement of Witness: I swear and affirm under penalty of perjury that the above appeared before me on this day of, 20, and proved to me to be the person(s) appearing before me. NAME OF WITNESS (PLEASE PRINT): SIGNATURE OF WITNESS: DATE: PLEASE FAX COMPLETED FINAL EXAM IDENTITY AFFIDAVIT FORMS TO (888)

17 CANDIDATE HANDBOOK, PROGRAM OUTLINE, AND APPLICATION 17 QUESTION CHALLENGE FORM ASSE 6040 MAINTENANCE PERSONNEL PROGRAM In order for us to properly review your challenge, please provide as much information as possible. NAME OF CANDIDATE: MAILING ADDRESS: Candidate Information (Please Print) CITY: STATE: ZIP: Question Challenges (Please Print) If in your judgment, there appears to be errors, please indicate the question number and a specific challenge provided in the space below. If additional space is required, use another sheet of paper and provide as much information as possible, but at least the information requested below. Please use one form per question challenge. EXAMINATION DATE: QUESTION NO.: REASON FOR CHALLENGE (PLEASE BE SPECIFIC): REFERENCE SUPPORTING CHALLENGE (IF AVAILABLE): ANSWER MARKED DURING EXAM (CIRCLE ONE): A B C D E PLEASE FAX COMPLETED QUESTION CHALLENGE FORMS TO (888)

18 CANDIDATE HANDBOOK, PROGRAM OUTLINE, AND APPLICATION 18 CERTIFICATION CHECKLIST ASSE 6040 MAINTENANCE PERSONNEL PROGRAM This checklist identifies all of the requirements that need to be fulfilled in order to complete the program. Please ensure that all of these requirements have been met before inquiring about your ASSE 6040 certification and card. Check List: Prior to Final Examination Completed & Faxed Candidate Application Form Paid Program Fees Completed all Training Modules for the ASSE 6040 program Completed ASSE 6040 Final Exam Review Module Completed & Faxed Final Exam Registration Form During the Final Examination Check List: A Copy of the Question Challenge Form (If needed) Completed Online Final Examination After Passing the Final Examination Check List: ed digital photograph of candidate (Per the following guidelines) to 6040photo@medgascerts.com or uploaded digital photograph of candidate to the website at Completed & Faxed Final Exam Identity Affidavit Form (Signed by a verifier of identity AND a witness) Candidate Photograph Guidelines: The photograph must be a full view of the head and face of the candidate (No dark glasses or hats). You must face directly into the camera (Do not look down or sideways) and eyes must be open. Your head must be fully visible and centered in the photograph and your face should be about 50% of the area. The photograph must be taken against a plain white or off-white background (Photos with Dark or patterned backgrounds will not be accepted). The photograph must have no distracting shadows. The photograph must be submitted in a JPEG format. The photograph must be in color using an srgb format. The photograph must NOT be compressed any more than 20:1. In general, most digital cameras will work for the photographs.