Lead Hazard Reduction



Lead-Based Paint Risk Assessment Report

Performed On: [Date] [Time]

For site located at:

[Address] [Street]

[Apartment or Unit # if applicable]

[City], WI [Zip]

Date of Construction:

[Year Built]

Prepared For:

[Owner’s Name]

[Owner’s Address]

[City], WI [Zip]

[Owner’s Phone]

[pic]

(insert picture of Risk Assessment Property above)

Risk Assessment and Report Completed By:

[Your Name], [LRA or LHI-xxxxxx], [Title]

[2nd Inspector Name], [LRA or LHI-xxxxxx], [Title] (delete if only one person or add others as needed)

For:

[Your Agency]

[Address]

[City], WI [Zip]

[Phone]

DHS Lead Company #[xxxxxx]

[Note: Delete all comments in RED before saving the final draft of your risk assessment report.

Remove yellow highlighting from areas where you inserted your own information. Yellow highlighting fields are required information in this report.]

Table of Contents

1.0 Description and Purpose of Report 3

2.0 Disclosure Responsibility 3

3.0 Disclaimer 3

4.0 Background Information 3

4.1 Physical Characteristics

4.2 Areas Not Accessible During the Assessment

4.3 Occupant Use Patterns

4.4 Building Maintenance and Renovations

5.0 Visual Inspection 4

5.1 Visual Assessment 4

5.2 Building Condition 5

6.0 Assessment Findings 5

6.1 Condition Assessment and XRF Readings (delete this section if XRF readings were not taken) 5

6.2 Condition Assessment and Paint Chip Samle Results (delete this section if paint chips were not collected) 8

6.3 Dust Wipe Sampling 11

6.4 Soil Sampling 12

6.5 Consumer Products and Children’s Toys Assessment and Sampling Results (remove if no children’s items were sampled) 13

7.0 Summary of Findings 13

7.1 Monitoring and Reevaluation

8.0 Lead Hazard Control Options 14

8.1 Component(s): Interior Windows 14

8.2 Component(s): Interior doors, door jambs and door casing trim 15

8.3 Component(s): Interior walls and backsplash 16

8.4 Component(s): Interior baseboards and associated system components 16

8.5 Component(s): Interior flooring 17

8.6 Component(s): Exterior siding, soffit and fascia 18

8.7 Component(s): Exterior window trim 18

8.8 Component(s): Exterior gutters and downspouts 19

8.9 Component(s): Roof 19

8.10 Component(s): Children’s toys and play areas 19

9.0 Standard Operating Procedure and Signature Page 20

APPENDIX A: XRF Performance Characteristic Sheet 21

APPENDIX B: Laboratory Analysis Report 1

APPENDIX C: Floor Plan 2

APPENDIX D: Pictures 3

APPENDIX E: Questionnaire……………………………………………………………………………..4

1.0 Description and Purpose of Report

(Edit as necessary to match your purpose and your findings.)

This report is the result of an investigation to identify lead hazards in a dwelling where a child lives or spends time and has been found with an elevated blood lead level. Wisconsin law requires health departments to investigate all properties where a child with an elevated blood lead level lives or spends time. The investigation focused on surface coatings that were either deteriorated, damaged, friction or impact surfaces, surfaces with evidence of chewing and areas of bare soil. Results from this assessment form the basis for the Lead Hazard Control Recommendations in this report. Detailed instructions describing the work required to address the hazards are located in Section 8.0 Lead Hazard Control Recommendations in this report. (Explain other sources that could contain lead. Example: Other potential sources of lead exposure such as toys, hobbies, work or take home exposure, dishes, food, or water.)

2.0 Disclosure Responsibility

A copy of this summary must be provided to new lessees (tenants) and purchasers of this property under federal law Title X Section 1018 before they become obligated under a lease or sales contract. The complete report must also be provided to new purchasers and it must be made available to new tenants. Landlords (lessors) and sellers are also required to distribute an educational pamphlet and include standard warning language in their leases or sales contracts to ensure that parents have the information they need to protect their children from lead-based paint hazards.

3.0 Disclaimer

This report is composed of a visual survey and samples of the readily accessible areas of this building and tested components. The presence or absence of lead-based paint or lead-based paint hazards applies only to tested or assessed surfaces on the date of the field visit. Because conditions may change, ongoing monitoring by the owner is necessary.

This document is provided for informational purposes only. The information contained in this document and these references represents the current view of the risk assessor on the issues discussed as of the date of publication. Information provided in this document is provided “as is” without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability, fitness for a particular purpose, and freedom from infringement. The user assumes the entire risk as to the accuracy and the use of this document. It is recommended to conduct a new assessment if it is more than 12 months from the assessment date in this report.

This document may be copied and distributed subject to the following conditions:

1. All text must be copied without modification and all pages must be included.

2. This document may not be distributed for profit.

Please review this report fully; including any REMARKS printed on each page, and call the risk assessor for an explanation of any aspect of this report, written or printed, that you do not fully understand.

4.0 Background Information

4.1 Physical Characteristics: Describe the physical characteristics of the dwelling. (Example: The property is a two-story upper/lower duplex rental home built in 1920 with an unfinished basement. A garage is located behind the dwelling.) Describe the neighboring properties. (Example: The property is bordered on the north, west, and south by residential dwellings and with a commercial building to the east.) Describe occupancy. (Example: The unit was occupied at the time of the assessment including two children under the age of six.)

Describe the areas that were tested and if any testing had been done before. (Example: Only the upper unit was assessed. The main stairwell to the unit and the surrounding yard and garage were included. No previous lead-based paint inspections or risk assessments of this property were known to exist at the time of this assessment.)

4.2 Areas Not Accessible During the Assessment: Describe any areas that were not accessible during the assessment. (Example: The master bedroom in the upper unit was not assessed at the time. Lead hazards may be present in that area. Children under the age of six should not enter this area until it has been assessed by a certified risk assessor or hazard investigator.)

4.3 Occupant Use Patterns: The assessor completed Housing and Urban Development (HUD) Questionnaire 16.1 with the occupants to help determine use patterns, cleaning habits, play areas, hobbies involving any form of lead, or other potential sources of lead that could be brought into the dwelling, or expose a young child to sources of lead outside the dwelling.

4.4 Building Maintenance and Renovations: Describe the maintenance history of the house and any garages or other outbuildings. Also describe any past or planned remodeling or renovation work. Indicate if there has not been regular maintenance or there has not been any renovation or remodeling work done or planned.

5.0 Visual Inspection

5.1 Visual Assessment

As part of this assessment, a visual inspection of the property and structure was conducted to identify potential lead hazards from deteriorated surface coatings, friction and impact surfaces, surfaces that show evidence of chewing, and areas of bare soil. Building components were surveyed for any possible underlying cause of the deterioration.

(Example: A visual assessment was conducted of the interior and exterior of this property. The following deteriorated coatings, friction, impact, or chewed surfaces and areas of bare soil were identified. These surfaces were evaluated to determine if a lead hazard is present. Refer to Section 7.0 Summary of Findings for results:

Interior (Examples, edit as necessary)

• Kitchen sides B, C and D: Peeling/chipping wainscot (brown and white)

• Bedroom #1 windowsill D3: Signs of chewing

• Bathroom ceiling: Peeling paint

• Bedroom 2 closet door: Friction

• Interior doors: Friction/impact

• All windows: Peeling/chipping paint in trough

Exterior of Dwelling (Examples, edit as necessary)

• Siding on side A (south side): Chipping/peeling paint

• Fascia and soffit all sides: Chipping/peeling

• Porch ceiling on side C: Chipping/peeling

• Screen door on side B: Impact

• All windows: Peeling/chipping paint in trough

Bare Soil/Play Areas/Out Buildings (Examples, edit as necessary)

• Drip line: Paint chips

• Swing set: Bare soil

• Detached garage: Peeling/chipping paint

5.2 Building Condition

In addition to a visual assessment, building conditions were identified that may contribute to the deterioration of coated surfaces.

Building Condition for Lead Hazard Risk Assessment

|Condition |Yes |No |Comments |

|Roof missing parts of surfaces (tiles, boards, shakes, | | | |

|etc.) | | | |

|Roof has holes or large cracks | | | |

|Gutters or downspouts broken | | | |

|Chimney masonry cracked, bricks loose or missing, | | | |

|obviously out of plumb | | | |

|Exterior or interior walls have obvious large cracks or | | | |

|holes, requiring more than routine pointing (if masonry) | | | |

|or painting | | | |

|Exterior siding has missing boards or shingles | | | |

|Water stains on interior walls or ceilings | | | |

|Walls or ceilings deteriorated | | | |

|More than very small* amount of paint in a room | | | |

|deteriorated | | | |

|Two or more windows or doors broken, missing, or boarded | | | |

|up | | | |

|Porch or steps have major elements broken, missing, or | | | |

|boarded up | | | |

|Foundation has major cracks, missing material, structure | | | |

|leans, or visibly unsound | | | |

|** Total number | | | |

* The very small amount is the de minimis amount under the HUD Lead-safe Housing Rule (24 CFR 35.1350(d)), or the amount of paint that is not “paint in poor condition” under the EPA lead training and certification (“402”) rule (40 CFR 745.223).

** If the “Yes” column has any checks, the dwelling is usually considered not to be in good condition for the purposes of a risk assessment and conducting a lead hazard screen is not advisable. However, specific conditions and extenuating circumstances should be considered before determining the final condition of the dwelling and the appropriateness of a lead hazard screen. If the “Yes” column has any checks, and a lead hazard screen is to be performed, describe below the extenuating circumstances that justify conducting a lead hazard screen.

Notes (including other conditions of concern): (Add any additional relevant information)

6.0 Assessment Findings

6.1 Condition Assessment and XRF Readings (delete this section and the corresponding heading in the table of content if an XRF was not used)

Lead in paint, varnish, shellac, or other surface coatings can be identified by laboratory analysis of paint chips or by direct readings using an XRF instrument. In this assessment a [manufacturer and model names] x-ray fluorescence instrument, serial number [xxxxxx], was used to test all deteriorated surfaces. The instrument determines lead measured in milligrams per square centimeter (mg/cm²) of the coating on the tested component. In Wisconsin an XRF reading equal to or greater than 1 milligram of lead per square centimeter (mg/cm²) in the dried film is defined as being lead-bearing.

The risk assessor followed manufacturer’s guidelines for operation of the instrument. The instrument’s calibration was checked before and after the assessment using a known quantity of lead on test films supplied by the National Institute for Standards and Technology (NIST) and found the instrument to be working within the manufacturer’s specifications.

(Calibration standards provided are for Heuresis Pbi 200. Edit if using a Niton or RMD.)

|Calibration Verification |

|Reason |Standard |XRF Reading |Pass/Fail |

| | |(mg/cm2) | |

|Pre-Verification |NIST Lead Paint Film Standard, 1 mg/cm2 | | |

| |(Calibration Check Limits: .8 to 1.2 mg/cm²) | | |

|Pre-Verification |NIST Lead Paint Film Standard, 1 mg/cm2 | | |

| |(Calibration Check Limits: .8 to 1.2 mg/cm²) | | |

|Pre-Verification |NIST Lead Paint Film Standard, 1 mg/cm2 | | |

| |(Calibration Check Limits: .8 to 1.2 mg/cm²) | | |

|Pre-Verification |NIST Film Standard 0.0 mg/cm2 | | |

| |(Calibration Check Limits: -0.2 to 0.2 mg/cm²) | | |

|Pre-Verification |NIST Film Standard 0.0 mg/cm2 | | |

| |(Calibration Check Limits: -0.2 to 0.2 mg/cm²) | | |

|Pre-Verification |NIST Film Standard 0.0 mg/cm2 | | |

| |(Calibration Check Limits: -0.2 to 0.2 mg/cm²) | | |

|Post-Verification |NIST Lead Paint Film Standard, 1 mg/cm2 | | |

| |(Calibration Check Limits: .8 to 1.2 mg/cm²) | | |

|Post-Verification |NIST Lead Paint Film Standard, 1 mg/cm2 | | |

| |(Calibration Check Limits: .8 to 1.2 mg/cm²) | | |

|Post-Verification |NIST Lead Paint Film Standard, 1 mg/cm2 | | |

| |(Calibration Check Limits: .8 to 1.2 mg/cm²) | | |

|Post-Verification |NIST Film Standard 0.0 mg/cm2 | | |

| |(Calibration Check Limits: -0.2 to 0.2 mg/cm²) | | |

|Post-Verification |NIST Film Standard 0.0 mg/cm2 | | |

| |(Calibration Check Limits: -0.2 to 0.2 mg/cm²) | | |

|Post-Verification |NIST Film Standard 0.0 mg/cm2 | | |

| |(Calibration Check Limits: -0.2 to 0.2 mg/cm²) | | |

(Delete and replace information in red below including room type, component, building side.)

Room:

|Component |Side |Substrate |Sample Result |Lead-based Paint|Treatment |

| | | |(mg/cm2) |Yes/No |Required |

| | | | | |Yes/No |

| | | | | | |

| | | | | | |

| | | | | | |

| | | | | | |

Notes:

Room:

|Component |Side |Substrate |Sample Result |Lead-based Paint|Treatment |

| | | |(mg/cm2 ) |Yes/No |Required |

| | | | | |Yes/No |

| | | | | | |

| | | | | | |

| | | | | | |

| | | | | | |

| | | | | | |

| | | | | | |

Notes:

Room:

|Component |Side | |Sample Result |Lead-based |Treatment |

| | |Substrate |(mg/cm2 ) |Paint |Required |

| | | | |Yes/No |Yes/No |

| | | | | | |

| | | | | | |

| | | | | | |

| | | | | | |

| | | | | | |

Notes:

Room:

|Component |Side | |Sample Result |Lead-based |Treatment |

| | |Substrate |(mg/cm2 ) |Paint |Required |

| | | | |Yes/No |Yes/No |

| | | | | | |

| | | | | | |

6.2 Condition Assessment and Paint Chip Sampling Results (delete this section and the corresponding heading in the table of content if paint chip sampling was not conducted)

Lead in paint, varnish, shellac, or other surface coatings can be identified by laboratory analysis of paint chips or by direct readings using an x-ray florescence (XRF) instrument. In this assessment, paint chip samples were collected in accordance with Appendix 13.2, Paint Chip Sampling found in the HUD Guidelines For The Evaluation and Control of Lead Based Paint Hazards in Housing.

In Wisconsin any applied coating that is equal to or greater than 0.5 percent (≥0.5%) lead by weight in the dried film is lead-bearing.

A total of [ xxx ] paint chip samples were collected and analyzed. Samples were analyzed by the:

Wisconsin Occupational Health Laboratory (WOHL)

2601 Agriculture Drive

Madison, WI 53718

608-224-6210Laboratory ID # 101070

(Below is an example showing rooms and components where paint chip samples were taken. Delete contents and replace with your paint chip sampling results. All areas of deterioration must be sampled.)

Room:

|Component |Side |Substrate |Sample Result |Lead-based Paint|Treatment |

| | | |(mg/cm2 or %) |Yes/No |Required |

| | | | | |Yes/No |

| | | | | | |

| | | | | | |

| | | | | | |

| | | | | | |

| | | | | | |

| | | | | | |

| | | | | | |

| | | | | | |

Notes:

Room:

|Component |Side |Substrate |Sample Result |Lead-based Paint|Treatment |

| | | |(mg/cm2 or %) |Yes/No |Required |

| | | | | |Yes/No |

| | | | | | |

| | | | | | |

| | | | | | |

| | | | | | |

| | | | | | |

Notes:

Room:

|Component |Side |Substrate |Sample Result |Lead-based Paint|Treatment |

| | | |(mg/cm2 or %) |Yes/No |Required |

| | | | | |Yes/No |

| | | | | | |

| | | | | | |

| | | | | | |

6.3 Dust Wipe Sampling

Dust wipe samples were collected following documented protocol and sampling methodologies found in Wisconsin Administrative Code DHS 163 and Appendix 13.1 Wipe Sampling of Settled Dust for Lead Determination found in the Housing and Urban Development (HUD) Guidelines For The Evaluation and Control of Lead Based Paint Hazards in Housing.

Field collection of settled dust samples using single surface wipe sampling methods is used to determine the presence of lead dust hazards on floors and on window sills in a residential structure. In Wisconsin a lead dust hazard is present if the arithmetic mean average of laboratory results for all like surfaces are equal to or are greater than 10 micrograms per square foot (µg/ft²) on floors and 100 µg/ft² on window sills.

A total of [ xxxx ] dust wipe samples were collected and analyzed. One additional field blank sample anonymously marked was included and analyzed as a quality control check. Samples were analyzed by the:

Wisconsin Occupational Health Laboratory (WOHL)

2601 Agriculture Drive

Madison, WI 53718

608-224-6210

Laboratory ID # 101070

Wipe Sampling Summary Table (Blanks must be ................
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