Free Property Investigation Report, DPH 4771C - Wisconsin

File Size: 45.6 kB
Pages: 1
Date: February 13, 2007
File Format: PDF
State: Wisconsin
Category: Health Care
Author: dhfs/dph/beoh/lead and asbestos
Word Count: 448 Words, 2,946 Characters
Page Size: Letter (8 1/2" x 11")

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

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

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 Last PROPERTY INFORMATION Street Address Owner Name Owner Street Address Year of Construction (Actual or Estimated): Address is (check one): Residence when EBLL identified Other (describe): Type of residence (check one): Section 8 Housing Owner Occupied Private Rental Public Housing Current residence Supplemental Address City Apt. No. City Telephone No. State Zip Code County Zip Code First MI Date of birth (mm/dd/yy):

Family received federally mandated "Protect Your Family from Lead in Your Home" pamphlet from landlord or previous owner when they first moved in or prior to purchase of home: Yes No PROPERTY INVESTIGATION INFORMATION Date Investigation Referred (mm/dd/yy) Date of Investigation (mm/dd/yy) Name of Certified Risk Assessor/Hazard Investigator:

Main Cause(s) of Lead Based Paint Hazard(s) or Exposure (check all that apply) Deterioration Remodeling Repainting/scraping/ sanding Repair Mouthing/chewing surfaces Eating non-food items No Hazards present property investigation closed Other (describe):

Location of Potential Hazard(s) (check all that apply) Interior Windows Doors Trim Other: Floors/stairs Walls Ceilings Exterior Windows Doors Soil Other: Siding Ceilings Porches

Method of Collection for Environmental Samples Interior Exterior XRF Dust wipe Paint chip XRF Dust wipe Paint chip Soil Owner:

Dates For Lead Hazard Reduction Completion (mm/dd/yy) Interior Exterior Interim controls Abatement Tenant: Interim controls Abatement

Date Property Investigation Report Sent to:

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. Yes No Stats. 254.166 (2) Other Lead Hazards or Sources Identified Based on Testing (check all that apply and describe): Mini-blinds Description: Send completed form 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 Hobby Work related Pottery Water Other: Folk remedies