Health Report For Foster And Adoptive Parents (Page 4 of 6) in pdf

Health Report For Foster And Adoptive Parents Page 4

Iowa Department of Human Services

Lead Paint Assessment

My place of residence was built before 1960. I certify that I have conducted a visual

assessment for lead hazards that exist in the form of peeling or chipping paint in my

residence.

I conducted the visual assessment on _________________________.

Date

I certify that I have applied interim controls using safe work methods if the presence of

peeling or chipping paint was found.

Interim controls are measures designed to temporarily reduce human exposure or likely

exposure to lead-based paint hazards, such as repairing deteriorated lead-based paint,

specialized cleaning, maintenance, painting, and temporary containment.

My visual assessment did not find any form of peeling or chipping paint in my

residence.

My visual assessment did find a form of peeling or chipping paint and I have

applied interim controls.

My visual assessment did find a form of peeling or chipping paint and I have not

applied interim controls.

I will apply the interim control measures by _________________________.

Date

Person who completed the visual assessment

470-4819 (7/09)

Health Report For Foster And Adoptive Parents Page 4