Lead-Based Paint
Renovation, Repair & Painting Rule
Tip/Complaint Form

Directions: Complete as much as possible. Fields with an asterisk * are required.

(a.) Name, address, and telephone number of Contractor(s):

(b.) Name, address and telephone number of Property owner(s) and/or manager(s) :

(c.) Address of residence or child-occupied facility where alleged violation occurred:

Street:
City	State: ZIP:

(d.) Your name, address, and telephone number:

2. General Information

(a.) Did the renovation, repair, or painting project disturb painted surfaces in a residence built before 1978 or a child-occupied facility?*

(b.) Do children currently live in the residence?*

(c.) If yes, what are their ages?

(d.) Are there children with elevated blood lead levels at this address?*

(e.) Type of Housing:*	If other:

3. Renovation

(a.) Type of renovation work that was completed:	If other:

(b.) Start date of renovation work:

(c.) Did the renovator disturb more than 6 square feet of interior painted surface?

(d.) Did the renovator disturb more than 20 square feet of exterior painted surface?

(e.) Is the firm EPA-certified?

(f.) Is the renovator EPA-trained?

(g.) Was the renovation work conducted using lead-safe work practices (for example, covering work areas with taped-down plastic sheeting, cleaning all surfaces and objects by using a High Efficiency Particulate Air ("HEPA") vacuum cleaner or wiping with a damp cloth, and performing cleaning verification)?

4. Notification

(a.) Did Owner/Tenant receive an EPA-approved lead hazard information pamphlet ("Renovate Right" pamphlet)

(b.) Did Owner/Tenant receive written notification prior to start of renovation?

(c) Is the renovation work still ongoing?

5. Comments