Instructions:  Complete this checklist for homes constructed prior to 1978.

     
Year Property Built

     					     						     
Borrower Last Name			Borrower First Name				MI

     
Property Address

     						     					     
City						State 					Zip		
1.	Does the property have an existing or outstanding work order from the Minnesota Department of Health requiring the lead work to occur?
 Yes	 No

If yes:
	The work is considered “regulated lead work” by the Minnesota Department of Health and the issues raised in the work order must be addressed.
		The work is not considered “regulated lead work” by the Minnesota Department of Health.

2.	Property is exempt from having a lead-based paint risk assessment and/or lead-based paint hazard reduction for the following reasons (check all that apply):
	Repairs are limited to those that are necessary to respond to an emergency.
	Rehabilitation will not disturb painted surfaces.
	The property was found by a certified lead-based paint inspector not to have lead-based paint.

If property is exempt, skip to signature section.

3.	Which lead-based paint test was used? (check all that apply):
	Conducted paint testing
	Conducted paint testing and performed risk assessment
	Performed lead hazard screen (in lieu of risk assessment)
	Presumed lead-based paint and/or lead-based paint hazards were present

4.	Were any painted surfaces above the “De Minims Levels” disturbed or repaired during the completion of rehabilitation work?
 Yes	 No

If No, property is exempt. Skip to signature section.
5.	Did the qualified person that conducted the initial visual assessment identify any deteriorated lead-based paint?
 Yes	 No

If No, property is exempt. Skip to signature section.

6.	Which lead hazard reduction method was used?
 Abatement
 Interim controls
 Standard treatment (only if presumed presence of lead-based paint)

7.	Did the contractor(s) that performed lead hazard reduction have the proper certification/training?
 Yes	 No

8.	Was temporary relocation of occupants necessary?
 Yes	 No

9.	The following documentation must be retained in file (check all that apply):

	Required Documentation	Date Completed	
	Copy of the lead-based paint inspection and/or risk assessment	     	
	Evidence that contractor(s)/worker(s) doing the lead-based paint reduction had the proper certification/training	     	
	Copy of each clearance test	     	
	Record of the distribution of the Lead Hazard Information pamphlet provided to occupants	     	
	Copy of the notice of evaluation or presumption received by Borrower	     	
	Copy of final clearance examination	     	
	Copy of each notice of lead hazard reduction activity2	     	

Authorized Signature		
     
Title

     
Date