Sample Record Keeping Forms

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SAMPLE RECORD KEEPING FORMS
Form 1. A sample form for recording information during asbestos-containing materials (ACM) reassessment.
Reinspection of Asbestos-Containing Materials
Reinspection of Asbesto
Location of asbestos- containing material (address, building, room, or general description):
Location of asbestos-
Type of asbestos - containing material(s ):
Type of asbestos - containing material(s ):
1. Sprayed - or troweled- on ceilings or walls
1. Sprayed - or troweled- on ceilings or walls
2. Sprayed - or troweled- on structural members
2. Sprayed - or troweled- on structural members
3. Insulation on pipes, tanks, or boiler
3. Insulation on pipes, tanks, or boiler
4. Other (describe):
4. Other (describe):
Abatement Status:
Abatement Status:
1.
1.
The material has been encapsulated____, enclosed____, neither__ __, removed____.
The material has been encapsulated____, enclosed____, neither__ __, removed____.
Assessment:
Assessment:
1. Evidence of physical damage:
1. Evidence of physical damage:
2. Evidence of water damage:
2. Evidence of water damage:
3. Evidence of delamination or other damage:
3. Evidence of delamination or other damage:
4. Degree of accessibility of the material:
4. Degree of accessibility of the material:
5. Degree of activity near the material:
5. Degree of activity near the material:
6. Location in an air plenum, air shaft, or airstream:
6. Location in an air plenum, air shaft, or airstream:
7. Other observations (including the condition of the encapsulan t or enclosure, if any):
7. Other observations (including the condition of the encapsulan t or enclosure, if any):
Recommended Action:
Signed:
Signed:
Date:
Date:
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(evaluator)
(evaluator)

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