DEPARTMENT OF HEALTH & FAMILY SERVICES Division of Public Health DPH 44018 (10/02)
STATE OF WISCONSIN Bureau of Occupational Health HFS 163, Wis. Admin. Code (608) 261-6876
REQUEST FOR REPAIRS
Read instructions below before completing. The tenant should complete the "Tenant Information" section and send to the property owner when a lead-based paint hazard is found. Lead-based paint that is chipping, peeling, cracking, or flaking is a hazard. It is also hazardous when a metal or vinyl covering separates from a lead-based painted surface. Typical places where lead-based paint hazards are found are listed below: Outside Inside § Siding peeling paint § Window - chipping paint § Porch chipping paint § Door Frame peeling paint § Soil paint chips found by home § Bathroom ceiling - bubbling paint § Fence - flaking paint § Wall - paneling separating from the paint § Stairs damaged rubber treads § Bedroom Floor cracking paint Lead-based paint hazards must be repaired or removed within 20 days after sending this form to your property owner. Deadline for some exterior hazards may be the next June. If your property owner fails to comply with the 20 day limit, contact your local health department or the Asbestos and Lead Section at (608) 261-6876. The property owner must complete the "Return Information" prior to giving this form to the tenant. This form must be delivered to the tenant according to the following timeline (under s. HFS 163.42(3), Wis. Admin. Code): § Within 60 days after entering the lead-safe registry. § For new rental agreements, prior to the start of new tenancy. § In the absence of a rental agreement, prior to the start of tenancy. Once the tenant submits this form, the property owner must complete the "Documentation of Receipt and Repair". This form must be kept by the property owner 1 year after the expiration of the certificate of lead-safe status.
To be completed by the tenant when a lead-based paint hazard is found. Send this form to the address listed under "Return Information". Name of Tenant (First, Middle, Last) Telephone Number ( ) Street Address Unit Number City (Optional) If a child under 6 lives here, an inside hazard must be repaired at least temporarily within 5 working days. Where is the needed repair located? Outside In a building common area, such as laundry room, hallway, stairs In your home Describe where and what needs repair (Ex: Kitchen wall has peeling paint, or bedroom door's vinyl covering is separating)
This section is to be completed by the property owner before leaving this form with the tenant. The tenant will return this form to the address listed below. Property Owner's Name Mailing Address City Home Telephone Number ( ) Pager Number ( ) Fax Telephone Number ( ) Email Address State Zip Cellular Phone Number ( )
DOCUMENTATION OF RECEIPT AND REPAIR
To be completed by the property owner or an agent receiving the form once it is submitted by the tenant. Date Form Received Name (First and Last) of Property Owner or Agent Receiving Form Date of Repair Name of Person Conducting Repair