Instructions for Completing DOH-1024

The attached is a multi-use form which is used for the following:

1. Application to an approved backflow prevention device tester certification course.
2. New certification as a backflow prevention device tester.
3. Renewal of certification as a backflow prevention device tester.
4. Your permanent record with the New York State Department of Health.

General Instructions

Any individual seeking certification as a General of Limited Tester in accordance with Section 5-1.31 (a)(3) of the New York State Sanitary Code must complete all personal, employment and certification information in Sections A, B, and C of the attached form, DOH-1024. Section D of the form is reserved for use by the Supervising Instructor at a New York State Department of Health approved Backflow Prevention Device Tester Certification Course.

New Certification - "General Tester"

The applicant must submit a completed application to and satisfactorily complete a New York State Department of Health approved tester certification course. The Supervising Instructor will record the student's grades and forward the application to the Bureau of Public Water Supply Protection (BPWSP) for processing.

New Certification - "Limited Tester"

The applicant must submit a completed application and proof of employment by a manufacturer as the agent for the servicing, maintaining and testing of backflow prevention directly to the BPWSP for processing.

Recertification - General and Limited Tester

To qualify for recertification, both a General and Limited Tester must submit a completed application and proof that they are still engaged in backflow prevention device testing to the BPWSP at least three months prior to the expiration date on their certificate.

Acceptable proof of testing would be photocopies of test results.

Successful completion of a recertification examination will also qualify an individual for recertification.

Any questions should be directed to: