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Collects provider identity and contact details, including service member/veteran status with required proof when applicable. Includes sections to request approval to teach approved courses or administer/proctor exams, describe training methods, list instructors and proctors with documentation, and identify the examination to be used. 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High St. Columbus, Ohio 43215  \nE-mail: [foodsafety@odh.ohio.gov](foodsafety@odh.ohio.gov)  \n\n| Name of Provider: |  |  | Contact Name: |  |\n| --- | --- | --- | --- | --- |\n| Street Address |  |  |  |  |\n| City | State | Zip |  | County |\n| Phone: | E-mail Address: |  |  |  |\n| Are you a United States Armed Forces service member or veteran, or the spouse or surviving spouse of a service member or veteran? |  |  | Yes No\u003Cbr>Ifyes, proof ofservice/veteran status must be attached. |  |\n\nFor further information, refer to the “Guidelines to the Ohio Department of Health’s Certification in Food Protection” on the ODH website or contact the Food Safety Program at (614) 644-7416.  \nFailure to provide all required information may result in denial of the request.  \nRequesting approval to:  \n(check all that apply) Teach Approved Course Proctor Exam  \n1. Name of course:  \nNote: if teaching a course, a detailed agenda indicating the topics to be covered and duration of each must be attached.  \n2. Describe methods of training to be used (e.g. online course, PowerPoint presentation, books, interactive computer programs, instructional videos, etc.  \n3. List names of all instructors and/or proctors working under the provider approval and submit documentation of approval from the course/exam company demonstrating approval to teach and/or proctor its course/exam. A valid Ohio manager certificate in food protection must also be submitted for each instructor.  \n4. Provide the name of the examination to be used:  \nI hereby certify that the information provided is correct to the best of my knowledge.  \n\n| Signature | Title | Date |\n| --- | --- | --- |\n\nFor Ohio Department of Health use only:  \n\n| Action Taken: | Date: |\n| --- | --- |\n\nODH Food Safety Program •(614) 644-7416 • [foodsafety@odh.ohio.gov](foodsafety@odh.ohio.gov)","cbCaiaETdKXspWhU","https://ap.wps.com/l/cbCaiaETdKXspWhU","pdf",270162,"English","# Provider Information\n# Approval Request (Teach/Proctor/Exam)\n## Course Name and Training Methods\n## Instructors/Proctors and Documentation\n## Examination Name\n# Certification and Signatures\n# ODH Use Only","[{\"question\":\"Who must the completed application be submitted to?\",\"answer\":\"The completed application and all requested material must be submitted to the Ohio Department of Health, BEHRP Food Safety Program, at the listed Columbus, Ohio address.\"},{\"question\":\"What information is required about the provider?\",\"answer\":\"The form requests the provider’s name, street address, city/state/zip, county, phone, email, and a contact name.\"},{\"question\":\"If requesting approval to teach or proctor, what additional items must be provided?\",\"answer\":\"The form requires course name, training methods, instructor and/or proctor names with approval documentation from the course/exam company, valid Ohio manager certificates for each instructor, and the name of the examination to be used.\"}]","Application for Approval as a Provider of Ohio Manager Certification in Food Protection | PDF",1790036841]