Free DEPARTMENT OF HEALTH & FAMILY SERVICES - Wisconsin

DEPARTMENT OF HEALTH & FAMILY SERVICES Division of Public Health DPH 4771D (Rev. 11/06)

STATE OF WISCONSIN ss. 254.15, 254.166, Wis. Stats. Phone (608) 266-5817 FAX (608) 267-0402

PROPERTY INVESTIGATION CLOSURE REPORT
Case Management Of Children with Elevated Blood Lead Levels* *Elevated Blood Lead Level (EBLL) = 1 venous Blood Lead Level (BLL) >20 mcg/dL OR 2 venous BLLs of >15 mcg/dL drawn at least 90 days apart. Completion of this form is mandatory for agencies contracting with the Division of Public Health for program funding. Personal identifiable information collected on this form is used to describe the causes and conditions of lead poisoning and to monitor services provided. Data will be used in the aggregate to assist research and project future service needs. CHILD INFORMATION Name of Child - Last First MI Date of birth (mm/dd/yy)

PROPERTY INFORMATION Street Address Apt. No. City County Zip Code

Name of Certified Risk Assessor/Hazard Investigator who conducted clearance: Completion dates of lead hazard reduction work (mm/dd/yy): Interior interim controls: Exterior interim controls:

Interior abatement: Date Property Investigation Closed: (mm/dd/yy)

Exterior abatement:

Reason Investigation Closed:

Property passed final visual clearance investigation and dust wipe samples met clearance standards and local health department provided results to the owner and occupants. Property with only exterior lead-based paint hazards passed final visual clearance investigation Other identified lead hazards removed. Specify:

If lead hazard reduction work not completed, describe further action taken:

Referred to local legal authorities Local health department has notified the owner and posted a notice that the property is untenantable, Wis. Stats. 704.07 (4), and unsafe, dilapidated or unsanitary and therefore a human health hazard, Wis. Stats. 254.59 (3), or a presence of lead hazards Wis. Stats. 254.166 (2) Other action described:

Comments:

Send completed form with clearance dust wipe results to: DEPARTMENT OF HEALTH & FAMILY SERVICES Division of Public Health Childhood Lead Poisoning Prevention Program P. O. Box 2659 , Room 145 Madison, WI 53701-2659