Free Lead-Based Paint (LBP) Investigation Summary Report, DPH 44013 - Wisconsin

DEPARTMENT OF HEALTH AND FAMILY SERVICES Division of Public Health DPH 44013 (03/02)

STATE OF WISCONSIN Bureau of Occupational Health HFS 163, Wis. Adm. Code

LEAD-BASED PAINT (LBP) INVESTIGATION SUMMARY REPORT
This form is due no later than the end of the month following the report period. Check the appropriate box and fill in requested information in designated area. Return completed form to the address listed at the bottom of page 2 of this form. REPORT PERIOD (Check one of the following) January-March April-June July-September October-December

COMPANY INFORMATION
Company Name Company's Department of Health and Family Services Lead Certification Number (DHFS Lead Cert. No.) Contact Person for Report Telephone No. ( ) Primary Lead Investigator Investigator's DHFS Lead Certification No. Type of Activity (List each activity separately.) Lead-free inspection Lead-safe investigation Partial Inspection Full Inspection Hazard screen Risk assessment EBL (optional)** Clearance Lead-free inspection Lead-safe investigation Partial Inspection Full Inspection Hazard screen Risk assessment EBL (optional)** Clearance Lead-free inspection Lead-safe investigation Partial Inspection Full Inspection Hazard screen Risk assessment EBL (optional)** Clearance Lead-free inspection Lead-safe investigation Partial Inspection Full Inspection Hazard screen Risk assessment EBL (optional)** Clearance Lead-free inspection Lead-safe investigation Partial Inspection Full Inspection Hazard screen Risk assessment EBL (optional)** Clearance LBP or Lead Hazard detected? Yes No

PROPERTY INVESTIGATION
Date Conducted Location of Property (street or fire address)*

Yes No

Yes No

Yes No

Yes No

DPH 44013 (03/02), Page 2 Company Name Company's Department of Health and Family Services Lead Certification Number (DHFS Lead Cert. No.) Date Conducted Location of Property (street or fire address)* Primary Lead Investigator Investigator's DHFS Lead Certification No. Type of Activity (List each activity separately.) Lead-free inspection Lead-safe investigation Partial Inspection Full Inspection Hazard screen Risk assessment EBL (optional)** Clearance Lead-free inspection Lead-safe investigation Partial Inspection Full Inspection Hazard screen Risk assessment EBL (optional)** Clearance Lead-free inspection Lead-safe investigation Partial Inspection Full Inspection Hazard screen Risk assessment EBL (optional)** Clearance Lead-free inspection Lead-safe investigation Partial Inspection Full Inspection Hazard screen Risk assessment EBL (optional)** Clearance Lead-free inspection Lead-safe investigation Partial Inspection Full Inspection Hazard screen Risk assessment EBL (optional)** Clearance LBP or Lead Hazard detected? Yes No

Yes No

Yes No

Yes No

Yes No

*Under HFS 163, Wis. Adm. Code, revised effective March 1, 2002, any lead company with a Certified Lead Sampling Technician, Hazard Investigator, Inspector or Risk Assessor on staff must file a quarterly report, even though no regulated activity was performed. The report now must identify the property location by street or fire code address. **EBL or Elevated Blood Levels
If you have questions please call (608) 261-6876. If faxing, please send it to (608) 266-9711. If mailing, use the Mailing Address listed below. Applications may be hand delivered to the Street Address. Return completed application to: Mailing Address Department of Health and Family Services Asbestos and Lead Section, Rm 137 P.O. Box 2659 Madison WI 53701-2659 Street Address Department of Health and Family Services Asbestos and Lead Section One West Wilson Street, Room 137 Madison WI 53703