lead-based paint hazard control & healthy homes …€¦ · lead-based paint hazard control...

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LEAD-BASED PAINT HAZARD CONTROL & HEALTHY HOMES PROGRAM APPLICATION FOR LEAD HAZARD CONTROL SERVICES A separate application must be completed for EACH address or unit PART 1 PROPERTY INFORMATION Date: ___________________ Application for (check one): o Owner-Occupied Unit o Renter-Occupied Unit o Vacant Unit Address: ____________________________________________________________________Unit#: __________ City: _______________________________________________ State: AZ Zip Code: ______________________ Phone: _________________Alt. Phone: _________________Email Address: _____________________________ PART 2 OWNER INFORMATION Name: ____________________________________Phone (if different from above): _______________________ Ownership Type (check one): o LLC o Partnership o Corporation o Individual Owner o Other Mailing Address (if different from above):__________________________________________________________ City: ___________________________________________________________State: AZ Zip Code:____________ Email Address: ___________________________________________________ PART 3 OCCUPANT INFORMATION Table 3.1- ALL OCCUPANTS LIVING IN THE HOME, ADULT AND CHILDREN, MUST BE LISTED BELOW. Include frequently visiting children under age 6. ID # _________________________ Date:_________ SFHA Zone______ In Project Area? o Yes o No Property Taxes? o Yes o No For Questions Contact: Pima County Lead Hazard Control Program Tel: (520) 724-6765 Email: [email protected] Occupant # Name Date of Birth Relationship to Primary Resident Length of Stay in Residence Visiting Child? (Y/N) 1 2 3 4 5 6 7 8 9 10 1

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Page 1: LEAD-BASED PAINT HAZARD CONTROL & HEALTHY HOMES …€¦ · LEAD-BASED PAINT HAZARD CONTROL & HEALTHY HOMES PROGRAM ... ADULT AND CHILDREN, MUST BE LISTED BELOW. Include frequently

LEAD-BASED PAINT HAZARD CONTROL & HEALTHY HOMES PROGRAM

APPLICATION FOR LEAD HAZARD CONTROL SERVICES

A separate application must be completed for EACH address or unit

PART 1 PROPERTY INFORMATION Date: ___________________

Application for (check one):

o Owner-Occupied Unit o Renter-Occupied Unit o Vacant Unit

Address: ____________________________________________________________________Unit#: __________

City: _______________________________________________ State: AZ Zip Code: ______________________

Phone: _________________Alt. Phone: _________________Email Address: _____________________________

PART 2 OWNER INFORMATION

Name: ____________________________________Phone (if different from above): _______________________

Ownership Type (check one): o LLC o Partnership o Corporation o Individual Owner o Other

Mailing Address (if different from above):__________________________________________________________

City: ___________________________________________________________State: AZ Zip Code:____________

Email Address: ___________________________________________________

PART 3 OCCUPANT INFORMATION

Table 3.1- ALL OCCUPANTS LIVING IN THE HOME, ADULT AND CHILDREN, MUST BE LISTED BELOW. Include frequently visiting children under age 6.

GRANTS MANAGEMENT& INNOVATION

GRANTS MANAGEMENT& INNOVATION

GRANTS MANAGEMENT& INNOVATION

GRANTS MANAGEMENT& INNOVATION

ID # _________________________Date:_________ SFHA Zone______In Project Area? o Yes o NoProperty Taxes? o Yes o No

For Questions Contact:Pima County Lead Hazard Control ProgramTel: (520) 724-6765Email: [email protected]

Occupant # Name Date of Birth Relationship to Primary Resident

Length of Stay in Residence

Visiting Child? (Y/N)

123456789

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Occupant # American Indian/ Alaska Native

Asian Black/African American

Native Hawaiian/ Other Pacific

Islander

White Hispanic? Yes/No

123456789

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The five racial categories to choose from are defined below. You should check as many as apply to you.

1. American Indian or Alaska Native: A person having origins in any of the original Peoples of North and SouthAmerica (including Central America), and who maintains tribal affiliation or community attachment.

2. Asian: A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indiansubcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the PhilippineIslands, Thailand, and Vietnam.

3. Black or African American: A person having origins in any of the black racial groups of Africa. Terms such as“Haitian” or “Negro” can be used in addition to “Black” or “African American.”

4. Native Hawaiian or Other Pacific Islander: A person having origins in any of the original peoples of Hawaii, Guam,Samoa, or other Pacific Islands.

5. White: A person having origins in any of the original peoples of Europe, the Middle East or North Africa.

The two ethnic categories you should choose from are defined below.

1. Yes; Hispanic or Latino. A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanishculture or origin, regardless of race. The term “Spanish origin” can be used in addition to “Hispanic” or “Latino.”

2. No; Not Hispanic or Latino. A person not of Cuban, Mexican, Puerto Rican, South or Central American, or otherSpanish culture or origin, regardless of race.

Table 3.2- Race and Ethnicity Data (Check all fields that apply)

Racial Categories Ethnicity

*Household income cannot exceed the listed HUD-designated Area Median Income (AMI) limits.

PIMA COUNTY 2019 AREA MEDIAN INCOME ANNUAL LIMITS

Persons in Family 1 2 3 4 5 6 7 8

Annual Income Limits (80%) $35,800 $40,900 $46,000 $51,100 $55,200 $59,300 $63,400 $67,500

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Table 3.3- Sources of IncomeFor each household occupant 18 and over, list source, amount, and frequency of pay.

* If necessary, attach additional filesRequired Supporting DocumentsIncome Definitions:• Full (gross) amount of wages/salary• Net income from the operation of a business or profession• Full amount of periodic payments from Social Security Income, Supplemental Social Security Income, or Social Security Disability Income• Full amount of periodic payments from annuities, insurance policies, retirement funds, pensions, disability of death benefits• Payments in lieu of earnings, such as unemployment and disability compensation, workers compensation, and severance pay• Welfare assistance payments

Proof of Income: Applicant and family members over 18 years of age have to submit proof of ALL income received. Program reserves the right to ask for additional income-related documentation to prove income eligibility, including the listed below.

• The four (4) most recent pay stubs

Name of Occupant:Source of Income Amount Frequency of Pay

Name of Occupant:Source of Income Amount Frequency of Pay

Name of Occupant:Source of Income Amount Frequency of Pay

Name of Occupant:Source of Income Amount Frequency of Pay

Name of Occupant:Source of Income Amount Frequency of Pay

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• Social Security (SSI) or Social Security Disability Income (SSDI) Award Letter• Signed statement Self-Employment• Signed statement of No Income• Signed statement of Participation in HUD’s Housing Choice Voucher (HCV) Program

Collect the following documents to confirm eligibility (failure to provide documentation may be reason for denial).

In addition to proof of income, you are required to include:

• Birth certificates for children under age 6 living full time in the home• Previous 2 months of bank statements for household occupants over 18 years old• Signed Statement for Visiting Children (if children under 6 are regular visitors)

* Recipients of HUD’s Housing Choice Voucher Program, including Section 8, can meet income eligibility requirements by signing the statement below, thereby permitting Program representatives to contact and receive income eligibility documentation from the local Housing Authority.

Statement of Participation in HUD’s HCV Program:

By signing this statement, I attest that I receive public housing or rental assistance from HUD, and consent to and approve of communications between the local housing authority and Program representatives. I consent to the Program receiving documents from the local housing authority confirming my income, eligibility, and participation in public housing or rental assistance from HUD; no other personal information may be requested or collected by the Program. I understand that I can revoke this consent at any time with written notice to the Program, and that the Program is obligated to protect my personal information pursuant to 24 CFR Part 214 and 5 USC § 552a.

Applicant Signature:_______________________________________________ Date: ___________________________

Program Representative Initials: ______________________________________Date: ___________________________

Part 4 Property Information

Please answer ALL of the following questions. Consult with your landlord, if necessary.

1. Was the house at the above listed address built before 1978? o Yes o No

2. Are property taxes for this home paid to date? o Yes o No

3. Does the house/apartment/unit have at least one bedroom? o Yes o No

4. Is this property or tenant currently participating in a HUD program? o Yes o No

If yes, please list the program here: __________________________________________

5. Are you be interested in learning about other home rehabilitation programs provided by Pima County? o Yes o No

Part 5 Special Considerations

Please answer ALL of the following questions, by checking “Yes”, “No”, or “Don’t Know”.

1. Is there a child under age 6 living or regularly visiting the listed address who has a blood lead level of 5µg/dL or higher? o Yes o No o Don’t Know

2. Would you be willing to share your child’s previously completed blood test results? o Yes o No o Don’t Know

3. Are any of the unit occupants pregnant? o Yes o No o Don’t Know

4. Are you willing to have your child(ren) retested 6 months after lead hazard control activities are complete to reassess their blood lead level? o Yes o No o Don’t Know

The Program may provide low- or no-cost blood lead level testing resources.*

5. Would household occupants have a place to go for up to 10 days, while lead hazards are being removed from the home? o Yes o No o Don’t Know

6. If you are the owner, would you be willing to contribute financially towards controlling lead hazards in the home? Your answer will not affect your eligibility for this Program. o Yes o No o Don’t Know

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Part 6 Acknowledgements and Additional Services/Resources

This Part is applicable ONLY to owner- or renter-occupants; not landlords.

Please initial next to the following statements if you agree they are true:

I acknowledge that I have received the “Protect Your Family from Lead in Your Home” pamphlet from staff, providing information about homes built before 1978 and their risk of present lead-based paint.

Initials______________________ Date ______________________

By initialing this statement I acknowledge that if I am eligible to participate in the Program, I agree to receive a lead inspection/risk assessment conducted by a qualified consultant at the home listed in this application.

Initials______________________ Date ______________________

By initialing this statement I acknowledge that if I am eligible to participate in the Program, I agree to receive a Healthy Homes assessment conducted by a qualified consultant at the home listed in this application (Owner-occupants only).

Initials______________________ Date ______________________

I understand that if lead hazards are found in my home, I may be required to temporarily relocate to a lead-safe lo-cation for a period of no more than 10 days. I understand that I will be provided with assistance to accommodate all household members, including myself, who are required to temporarily relocate.

Initials______________________ Date ______________________

ADDITIONAL SERVICES RESOURCES

o I DO o I DO NOT agree to receive health and safety education from the Pima County Health Department.For more information on Pima County health programs, view our website at: http://webcms.pima.gov/government/health_department/ or call: 520-724-7770

*Low- or No-Cost Blood Lead Level Testing: It is not possible to tell if a child or family member is poisoned unless they are tested, because the signs of lead poisoning often take years to develop and are easily misdiagnosed without a test. The Program strongly recommends that all children under age 6 be tested for blood lead poisoning before lead hazard reduction work begins on the eligible property. Include children under age 6 who are frequent visitors (6 hours per week, or ten weeks per year).

Blood lead tests can be provided by your regular pediatrician at your request, usually at no cost to you. If you do not currently have a primary care physician or pediatrician, you can schedule an appointment for a blood lead test with:

Lorena VerdugoCommunity Health Coordinator for El Rio HealthCall: (520)370-3686 or Email: [email protected]

Any information you share with the clinic listed above will be treated as confidential as required by law.

PIMA COUNTY HOME REPAIR & WEATHERIZATION PROGRAM

If you own and occupy your home, enrollment and participation in the Lead-Based Paint Hazard Control & Healthy Homes (LBPHC) Program automatically makes you eligible to participate in Pima County’s Home Repair and Weather-ization (HR & WZ) Program. By signing below, you confirm that you want to participate in the HR & WZ Program and you authorize that this application, and collected eligibility documentation, be provided to the HR & WZ Program to automatically enroll your household into the HR & WZ Program.

_________________________________ _____________________________Signature Date

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I certify under penalty of law that the information contained in this declaration is true, accurate, and completed to the best of my knowledge. I understand that there are significant penalties for submitting false information, including the possibility of fines and imprisonment for knowing violations.

I agree to report any changes in circumstances immediately to the Program. I understand that my signature on this application indicates that family income does not exceed Area-Median-Income limits.

Property Owner name (PRINT): _______________________________________________________________________ Signature:___________________________________________________________Date: _________________________

Property Owner name (PRINT): _______________________________________________________________________ Signature:___________________________________________________________Date: _________________________

Tenant Owner name (PRINT): ________________________________________________________________________ Signature:___________________________________________________________Date: _________________________

Tenant Owner name (PRINT): ________________________________________________________________________ Signature:___________________________________________________________Date: _________________________

The Pima County Lead-Based Paint Hazard Control & Healthy Homes Program does not discriminate against any individual or group because of race, sex, religion, age, national origin, color, marital status, disability, or political belief.

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LEAD-BASED PAINT HAZARD CONTROL & HEALTHY HOMES PROGRAM In partnership with the Pima County Health Department and El Rio Neighborhood Health Center

FAMILY CONSENT FORM

You have applied for your home to be evaluated for hazards from lead-based paint, dust and soil. If hazards are found, they will be addressed by the Pima County Lead Hazard Control & Healthy Homes Program (“Program”). The participa-tion of your family in this Program is completely voluntary, and will include health and safety education from the Pima County Health Department (“PCHD”) for adults who are members of the household. This Program offers low- or no-cost blood lead testing of any children under six years of age or who live in the home or spend a significant amount of time in the home, and any pregnant women living in the home. While blood lead testing is not required to receive services, it is the only way to tell if you or your child has been lead poisoned, and is therefore strongly recommended.

Services provided by the program include lead-based paint, dust, and soil testing, which takes two to five (2–5) hours to complete. Lead testing appointments are scheduled in advance, at a mutually convenient time. Program personnel will notify applicants if hazards are found, and if corrective action is needed. In some cases, temporary relocation may be needed for health and safety reasons. If temporary relocation is needed to address lead-related hazards, it will be at the expense of the Program, not the applicant.

Family Participation

If Lead Hazards are Found: The Centers for Disease Control and Prevention recommends that all children under six years of age, especially those who live in housing built prior to 1978, be tested for lead. If lead hazards are found in the home, Program recommends that blood samples be collected from the arm of children under six years of age and pregnant women. Blood draws are conducted by a qualified staff of El Rio Neighborhood Health Center (“El Rio”). The risks of the blood collection process include soreness and a small bruise at the site, a small blood clot or swelling at or around the vein, or slight bleeding from the site. It will be necessary for an adult who is a member of the household to assist the nurse by holding children during this process.

If a child or pregnant occupant’s blood lead level is 5 µg/dL or greater, the Arizona Department of Health Services (ADHS) will be notified, as required by state law. El Rio and the PCHD will then assist families with children and preg-nant women who have an elevated blood lead level (5 µg/dL or greater). Medical information is protected by law and will be handled as confidential by the Program, ADHS, El Rio, and PCHD. If you are in a rental unit, blood lead results and other health related information will not be shared with your landlord. As the property owner, the landlord will be informed of all lead-based paint, dust and soil testing results.

Medical information is protected by law and will be handled as confidential by the Program, ADHS, El Rio, and PCHD. If you are in a rental unit, blood lead results and other health related information will not be shared with your landlord. As the property owner, the landlord will be informed of all lead-based paint, dust and soil testing results.

After Lead Hazards are Addressed: About six weeks after the lead control process, the staff from El Rio will make contact to arrange a follow-up lead test. This test will evaluate whether there was a decrease in blood lead levels after identified lead hazards were addressed in the home.

Applicant: ________________________________________________________________________________________ (Print Clearly) (First) (Middle) (Last) Address: __________________________________________________________________________________________ (Print Clearly) (City) (State) (Zip Code)

GRANTS MANAGEMENT& INNOVATION

GRANTS MANAGEMENT& INNOVATION

GRANTS MANAGEMENT& INNOVATION

GRANTS MANAGEMENT& INNOVATION

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Please select one of the options below:

o There are no children under six years of age who live in the home or spend a significant amount of time in the home.

o There is/are ______ child(ren) under six years of age who live in the home.

o There is/are ______ pregnant women who live in the home.

o There is/are ______ child(ren) under six years of age who frequently visit the home for a significant amount of time.

Applicant Signature: ____________________________________ Date: _________________

* * * * * MEDICAL CONSENT FOR PREGNANT WOMEN LIVING IN THE HOME ONLY * * * * *

o I DO o I DO NOT agree to have my blood tested for lead.

o I DO o I DO NOT agree to receive health and safety education.

o I DO o I DO NOT agree to share my blood lead test results with the Program.

Signature: ___________________________________________ Date: _________________

An Authorization for Use or Disclosure of Protected Health Information form must be completed if blood lead testing is conducted.

* * * * * MEDICAL CONSENT FOR CHILDREN (must be completed by Parent/Legal Guardian) * * * * *

oI DO o I DO NOT agree to have my child(ren)’s blood tested for lead.

oI DO o I DO NOT agree to receive health and safety education (for adult household members)

oI DO o I DO NOT agree to share my child(ren)’s blood lead test results with the Program.

An Authorization for Use or Disclosure of Protected Health Information form must be completed for each child listed below who will have a blood test for lead:

CHILD’S NAME FIRST DATE HOME ADDRESS INSURED AHCCCS OR AND LAST OF BIRTH YES OR NO OTHER

Parent/Legal Guardian Name: _________________________________________________________________________ (Print Clearly) (First) (Middle) (Last)

Parent/Legal Guardian Address: _______________________________________________________________________ Primary Phone: _________________________________ Other Phone: ______________________________

o Home o Work o Cell o Home o Work o Cell

Parent/Legal Guardian Signature: ______________________________________ Date: _____________________

Any person who knowingly makes a false statement or misrepresentation in an application or in support of an application for federal assistance, or causes such a false statement or misrepresentation to be made, shall be subject to a fine of not more than $5,000 or by imprisonment for not more than 2 years or both under provisions of the United States Criminal Code.

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Authorization for Use or Disclosure of Protected Health Information

Patient’s Name: _____________________________ Date of Birth: ____ / ____ / ____

I authorize communication between the following: Pima County’s Lead-Based Paint Hazard Control & Healthy Homes Program and El Rio Neighborhood Health Center regarding my blood lead test results. In accordance with Arizona state law, the Privacy Rule of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), and 42 CFR 2.35, I understand the following:

1. Voluntary Authorization. Signing this authorization is voluntary. My treatment, payment, enrollment in a health plan, or eligibility for benefits will not be conditioned upon my authorization of this disclosure.

2. Redisclosure. Information disclosed to a third party under this authorization may no longer be protected by state or federal law and might be redisclosed by the recipient, with the following exceptions: If I authorize the release of information related to alcohol/drug abuse, communicable diseases (including HIV/AIDS), or medical records or payment records, the recipient is prohibited from redisclosing the information without my authorization, unless permitted to do so under federal or state law. See 42 CFR Part 2, A.R.S. § 36-664(G), A.R.S § 12-2802(F), and A.R.S. § 12-2294(E).

3. Specific Authorizations. Disclosure of information relating to alcohol/drug abuse, mental health treatment (except psychotherapy notes), and communicable diseases (including HIV/AIDS) require specific authorization. I do not authorize the release of such information.

I authorize the following additional entities to provide and receive information (specify):

__________________________________________________________________________________________________

Purpose/Scope. The purpose of and need for the disclosure of the blood lead test results allow the Pima County Lead-Based Paint Hazard Control & Healthy Homes Program to complete grant-required reports that include data regarding blood lead test results. ________________________________________________ _______________________________________________Signature (Patient/Parent/Guardian/Other*). Date *If signed by someone other than Patient, please specify relationship/authority for signing.

________________________________________________ _______________________________________________Witness Date

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Confirmation of Blood Testing

The only way to know if your child has blood lead poisoning is to have them tested. In addition to your private physician, blood lead testing is available at no-cost to you through the following organization:

El Rio Health Clinic/LabsPlease visit the El Rio Congress Lab (839 W. Congress) or the El Pueblo Lab (228 W. Irvington) to perform a blood test on your child (ren), frequently visiting child(ren), or a pregnant woman.

If you have questions please contact: Lorena Verdugo at # (520) 370-3686.

On __________________ (date) ______________________________________ (name) had blood test (s) performed.El Rio Clinic Staff

White Copy – El Rio Yellow Copy – Homeowner/Renter/Client Pink Copy – Pima County

Return to Pima County Lead-Based Paint Hazard Control & Healthy Homes Program, 801 W. Congress Street, 85745, once your child, the frequently visiting child, or pregnant woman, has been tested.

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PIMA COUNTY LEAD-BASED PAINT HAZARD CONTROL & HEALTHY HOMES PROGRAM

CERTIFICATION OF NO INCOME

I, _____________________________________, certify that I have not earned or received any type of income.

Income includes but is not limited to:

• Gross wages, salaries, overtime pay, commissions, fees, tips and bonuses • Net income from operation of a business or from rental or real personal property • Interest, dividends and other net income of any kind for real personal property • Periodic payments received from Social Security, annuities, insurance policies, retirement funds, pensions, disability or death benefits and other similar types of period receipts • Lump sum payment(s) for the delayed start of a periodic payment (except as provided in 24 CFR 5.609 (b)(5)) • Payments in lieu of earnings, such as unemployment and disability compensation, worker’s compensation, and severance pay • Public assistance • Alimony and child support payments (whether through the court system or not) • Regular pay, special pay and allowances of a head of household or spouse who is a member of the Armed Forces (whether or not living in the dwelling) • Regular monetary gifts from family and/or friends

I have stated during the verification process that I have no income at this time. I have not earned or received any of the above incomes during the period of:

_______________________________________________ to _____________________________________________ (mm/dd/yyyy) (mm/dd/yyyy)

I understand that any misrepresentation or failure to disclose information requested on this form may disqualify me from participation in the Program, and may be grounds for termination of assistance.

I hereby certify that the information I have provided is true and complete to the best of my knowledge.

WARNING: It is unlawful to knowingly provide false information to the government when applying for federal public benefit programs per the Program Fraud Civil Remedies Act of 1986, 31 U.S.C. §§ 3801-3812.

________________________________________________ _____________________________________________Applicant or Household Member Date

GRANTS MANAGEMENT& INNOVATION

GRANTS MANAGEMENT& INNOVATION

GRANTS MANAGEMENT& INNOVATION

GRANTS MANAGEMENT& INNOVATION

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PROGRAMA DE CONTROL DE RIESGO DE PINTURAS A BASE DE PLOMO Y HOGARES SALUDABLES

CERTIFICACIÓN DE NO INGRESO

Yo, __________________________________, certifico que no he ganado ni recibido ningún tipo de ingreso.

Ingreso puede constar de; pero no está limitado a:

• Salario bruto, salario, pago por horas extras, comisión, propinas y bonos• Ingreso neto de la operación de un negocio o de la renta o propiedad personal• Interés o pagos de otro tipo de ingreso neto o cualquier tipo de propiedad personal• Pagos por periodo recibido del Seguro Social, anualidades, pólizas de seguro, fondos de retiro, pensión, incapacidad o beneficio de defunción u otro tipo de recibos • Pago de suma total por el retraso de un pago por periodo (excepto en el caso de 24 CFR 5.609 (b)(5))• Pagos en lugar de ingresos, como por ejemplo la compensación por desempleo o incapacidad, compensación de trabajo o indemnización por despido• Asistencia pública• Pagos de pensión alimenticia (sean o no por el sistema judicial)• Pago regular, pago especial y ayuda a cabezas de familia o a la pareja de un miembro de las Fuerzas Armadas (vivan o no en el hogar)• Regalos en efectivo regulares de familiares y/o amigos

He declarado durante este periodo de verificación que no tengo ingreso. No he ganado o recibido cualquier tipo de ingreso de la lista anterior durante el lapso de:

_______________________________________________ a _______________________________________________ (mm/dd/aaaa) (mm/dd/aaaa)

Entiendo que cualquier falta de representación o divulgación de información requerida en este formulario me puede descalificar para participar en el Programa y puede ser el motivo por el cual se cancele la ayuda otorgada.

Certifico que la información que he proporcionado es verdadera y ha sido contestada de acuerdo a mi conocimiento.

AVISO: Es ilegal que conscientemente proporcione información falsa al gobierno cuando está solicitando asistencia de programas federales según la Ley de Remedios Civiles contra el Fraude de 1986, 31 U.S.C. §§ 3801-3812.

________________________________________________ _____________________________________________Solicitante o Miembro de Familia Fecha

GRANTS MANAGEMENT& INNOVATION

GRANTS MANAGEMENT& INNOVATION

GRANTS MANAGEMENT& INNOVATION

GRANTS MANAGEMENT& INNOVATION

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In Partnership with Sonora Environmental Research Institute

LEAD-BASED PAINT HAZARD CONTROL & HEALTHY HOMES (LBPHC) PROGRAM

Visiting Children Documentation/Documantación de Niños Visitantes

For eligibility purposes only, “frequently visiting” is visiting regularly by the same child, under six (6) years of age, on at least three (3) different days within any week (Sunday through Saturday inclusively), provided the combined weekly visits last for a minimum of six (6) hours total.

Para fines de elegibilidad, "visitar con frecuencia" es que el niño menor de 6 años visite regularmente la casa por lo menos tres (3) días en una semana (domingo a sábado), siempre que las visitas semanales combinadas sean mínimo de seis (6) horas.

Certfication/Certificación

I hereby certify that the child/children listed below are under the age of six (6) years and regularly visit the property located at _______________________________________ ________________________________ with equal or greater frequency than described in the above Pima County LBPHC definition.

Por la presente certifico que el / los niño (s) mencionado (s) abajo son menores de seis (6) años y visitan regularmente la propiedad ubicada en _________________________ _________________________________ con igual o mayor frecuencia que la descrita en la definición anterior.

Child’s Name Date of Birth Relationship Duration/Frequency of Visits

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________ Parent/Guardian Signature

_____________________________________________ SERI or LBPHC Staff Signature

__________________________ Date

__________________________ Date

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ProtectYourFamilyFromLead in YourHome

United States Environmental Protection Agency

United States Consumer Product Safety Commission

United States Department of Housing and Urban Development

June 2017

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Are You Planning to Buy or Rent a Home Built Before 1978?

Did you know that many homes built before 1978 have lead-based paint? Lead from paint, chips, and dust can pose serious health hazards.

Read this entire brochure to learn:

• How lead gets into the body• How lead affects health• What you can do to protect your family• Where to go for more information

Before renting or buying a pre-1978 home or apartment, federal law requires:

• Sellers must disclose known information on lead-based paint or lead-based paint hazards before selling a house.

• Real estate sales contracts must include a specific warning statement about lead-based paint. Buyers have up to 10 days to check for lead.

• Landlords must disclose known information on lead-based paint and lead-based paint hazards before leases take effect. Leases must include a specific warning statement about lead-based paint.

If undertaking renovations, repairs, or painting (RRP) projects in your pre-1978 home or apartment:

• Read EPA’s pamphlet, The Lead-Safe Certified Guide to Renovate Right, to learn about the lead-safe work practices that contractors are required to follow when working in your home (see page 12).

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Simple Steps to Protect Your Familyfrom Lead Hazards

If you think your home has lead-based paint:

• Don’t try to remove lead-based paint yourself.

• Always keep painted surfaces in good condition to minimize deterioration.

• Get your home checked for lead hazards. Find a certified inspector or risk assessor at epa.gov/lead.

• Talk to your landlord about fixing surfaces with peeling or chipping paint.

• Regularly clean floors, window sills, and other surfaces.

• Take precautions to avoid exposure to lead dust when remodeling.

• When renovating, repairing, or painting, hire only EPA- or state-approved Lead-Safe certified renovation firms.

• Before buying, renting, or renovating your home, have it checked for lead-based paint.

• Consult your health care provider about testing your children for lead. Your pediatrician can check for lead with a simple blood test.

• Wash children’s hands, bottles, pacifiers, and toys often.

• Make sure children eat healthy, low-fat foods high in iron, calcium, and vitamin C.

• Remove shoes or wipe soil off shoes before entering your house.

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Lead Gets into the Body in Many Ways

Adults and children can get lead into their bodies if they:

• Breathe in lead dust (especially during activities such as renovations, repairs, or painting that disturb painted surfaces).

• Swallow lead dust that has settled on food, food preparation surfaces, and other places.

• Eat paint chips or soil that contains lead.

Lead is especially dangerous to children under the age of 6.

• At this age, children’s brains and nervous systems are more sensitive to the damaging effects of lead.

• Children’s growing bodies absorb more lead.

• Babies and young children often put their hands and other objects in their mouths. These objects can have lead dust on them.

Women of childbearing age should know that lead is dangerous to a developing fetus.

• Women with a high lead level in their system before or during pregnancy risk exposing the fetus to lead through the placenta during fetal development.

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Health Effects of Lead

Lead affects the body in many ways. It is important to know that even exposure to low levels of lead can severely harm children.

In children, exposure to lead can cause:

• Nervous system and kidney damage

• Learning disabilities, attention-deficit disorder, and decreased intelligence

• Speech, language, and behavior problems

• Poor muscle coordination

• Decreased muscle and bone growth

• Hearing damage

While low-lead exposure is most common, exposure to high amounts of lead can have devastating effects on children, including seizures, unconsciousness, and in some cases, death.

Although children are especially susceptible to lead exposure, lead can be dangerous for adults, too.

In adults, exposure to lead can cause:

• Harm to a developing fetus

• Increased chance of high blood pressure during pregnancy

• Fertility problems (in men and women)

• High blood pressure

• Digestive problems

• Nerve disorders

• Memory and concentration problems

• Muscle and joint pain3

HearingProblems

Brain Nerve Damage

Slowed Growth

Reproductive Problems (Adults)

Digestive Problems

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Check Your Family for Lead

Get your children and home tested if you think your home has lead.

Children’s blood lead levels tend to increase rapidly from 6 to 12 months of age, and tend to peak at 18 to 24 months of age.

Consult your doctor for advice on testing your children. A simple blood test can detect lead. Blood lead tests are usually recommended for:

• Children at ages 1 and 2

• Children or other family members who have been exposed to high levels of lead

• Children who should be tested under your state or local health screening plan

Your doctor can explain what the test results mean and if more testing will be needed.

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Where Lead-Based Paint Is Found

In general, the older your home or childcare facility, the more likely it has lead-based paint.1

Many homes, including private, federally-assisted, federally-owned housing, and childcare facilities built before 1978 have lead-based paint. In 1978, the federal government banned consumer uses of lead-containing paint.2

Learn how to determine if paint is lead-based paint on page 7.

Lead can be found:

• In homes and childcare facilities in the city, country, or suburbs,

• In private and public single-family homes and apartments,

• On surfaces inside and outside of the house, and

• In soil around a home. (Soil can pick up lead from exterior paint or other sources, such as past use of leaded gas in cars.)

Learn more about where lead is found at epa.gov/lead.

1 “Lead-based paint” is currently defined by the federal government as paint with lead levels greater than or equal to 1.0 milligram per square centimeter (mg/cm), or more than 0.5% by weight.

2 “Lead-containing paint” is currently defined by the federal government as lead in new dried paint in excess of 90 parts per million (ppm) by weight.

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Identifying Lead-Based Paint and Lead-Based PaintHazards

Deteriorating lead-based paint (peeling, chipping, chalking, cracking, or damaged paint) is a hazard and needs immediate attention. Lead-based paint may also be a hazard when found on surfaces that children can chew or that get a lot of wear and tear, such as:

• On windows and window sills

• Doors and door frames

• Stairs, railings, banisters, and porches

Lead-based paint is usually not a hazard if it is in good condition and if it is not on an impact or friction surface like a window.

Lead dust can form when lead-based paint is scraped, sanded, or heated. Lead dust also forms when painted surfaces containing lead bump or rub together. Lead paint chips and dust can get on surfaces and objects that people touch. Settled lead dust can reenter the air when the home is vacuumed or swept, or when people walk through it. EPA currently defines the following levels of lead in dust as hazardous:

• 40 micrograms per square foot (μg/ft2) and higher for floors, including carpeted floors

• 250 μg/ft2 and higher for interior window sills

Lead in soil can be a hazard when children play in bare soil or when people bring soil into the house on their shoes. EPA currently defines the following levels of lead in soil as hazardous:

• 400 parts per million (ppm) and higher in play areas of bare soil

• 1,200 ppm (average) and higher in bare soil in the remainder of the yard

Remember, lead from paint chips—which you can see—and lead dust—which you may not be able to see—both can be hazards.

The only way to find out if paint, dust, or soil lead hazards exist is to test for them. The next page describes how to do this. 6

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Checking Your Home for Lead

You can get your home tested for lead in several different ways:

• A lead-based paint inspection tells you if your home has lead-based paint and where it is located. It won’t tell you whether your home currently has lead hazards. A trained and certified testing professional, called a lead-based paint inspector, will conduct a paint inspection using methods, such as:

• Portable x-ray fluorescence (XRF) machine

• Lab tests of paint samples

• A risk assessment tells you if your home currently has any lead hazards from lead in paint, dust, or soil. It also tells you what actions to take to address any hazards. A trained and certified testing professional, called a risk assessor, will:

• Sample paint that is deteriorated on doors, windows, floors, stairs, and walls

• Sample dust near painted surfaces and sample bare soil in the yard

• Get lab tests of paint, dust, and soil samples

• A combination inspection and risk assessment tells you if your home has any lead-based paint and if your home has any lead hazards, and where both are located.

Be sure to read the report provided to you after your inspection or risk assessment is completed, and ask questions about anything you do not understand.

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Checking Your Home for Lead, continued

In preparing for renovation, repair, or painting work in a pre-1978 home, Lead-Safe Certified renovators (see page 12) may:

• Take paint chip samples to determine if lead-based paint is present in the area planned for renovation and send them to an EPA-recognized lead lab for analysis. In housing receiving federal assistance, the person collecting these samples must be a certified lead-based paint inspector or risk assessor

• Use EPA-recognized tests kits to determine if lead-based paint is absent (but not in housing receiving federal assistance)

• Presume that lead-based paint is present and use lead-safe work practices

There are state and federal programs in place to ensure that testing is done safely, reliably, and effectively. Contact your state or local agency for more information, visit epa.gov/lead, or call 1-800-424-LEAD (5323) for a list of contacts in your area.3

3 Hearing- or speech-challenged individuals may access this number through TTY by calling the Federal Relay Service at 1-800-877-8339.

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What You Can Do Now to Protect Your Family

If you suspect that your house has lead-based paint hazards, you can take some immediate steps to reduce your family’s risk:

• If you rent, notify your landlord of peeling or chipping paint.

• Keep painted surfaces clean and free of dust. Clean floors, window frames, window sills, and other surfaces weekly. Use a mop or sponge with warm water and a general all-purpose cleaner. (Remember: never mix ammonia and bleach products together because they can form a dangerous gas.)

• Carefully clean up paint chips immediately without creating dust.

• Thoroughly rinse sponges and mop heads often during cleaning of dirty or dusty areas, and again afterward.

• Wash your hands and your children’s hands often, especially before they eat and before nap time and bed time.

• Keep play areas clean. Wash bottles, pacifiers, toys, and stuffed animals regularly.

• Keep children from chewing window sills or other painted surfaces, or eating soil.

• When renovating, repairing, or painting, hire only EPA- or state-approved Lead-Safe Certified renovation firms (see page 12).

• Clean or remove shoes before entering your home to avoid tracking in lead from soil.

• Make sure children eat nutritious, low-fat meals high in iron, and calcium, such as spinach and dairy products. Children with good diets absorb less lead.

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Reducing Lead Hazards

Disturbing lead-based paint or removing lead improperly can increase the hazard to your family by spreading even more lead dust around the house.

• In addition to day-to-day cleaning and good nutrition, you can temporarily reduce lead-based paint hazards by taking actions, such as repairing damaged painted surfaces and planting grass to cover lead-contaminated soil. These actions are not permanent solutions and will need ongoing attention.

• You can minimize exposure to lead when renovating, repairing, or painting by hiring an EPA- or state-certified renovator who is trained in the use of lead-safe work practices. If you are a do-it-yourselfer, learn how to use lead–safe work practices in your home.

• To remove lead hazards permanently, you should hire a certified lead abatement contractor. Abatement (or permanent hazard elimination) methods include removing, sealing, or enclosing lead-based paint with special materials. Just painting over the hazard with regular paint is not permanent control.

Always use a certified contractor who is trained to address lead hazards safely.

• Hire a Lead-Safe Certified firm (see page 12) to perform renovation, repair, or painting (RRP) projects that disturb painted surfaces.

• To correct lead hazards permanently, hire a certified lead abatement professional. This will ensure your contractor knows how to work safely and has the proper equipment to clean up thoroughly.

Certified contractors will employ qualified workers and follow strict safety rules as set by their state or by the federal government.

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Reducing Lead Hazards, continued

If your home has had lead abatement work done or if the housing is receiving federal assistance, once the work is completed, dust cleanup activities must be conducted until clearance testing indicates that lead dust levels are below the following levels:

• 40 micrograms per square foot (μg/ft2) for floors, including carpeted floors

• 250 μg/ft2 for interior windows sills

• 400 μg/ft2 for window troughs

For help in locating certified lead abatement professionals in your area, call your state or local agency (see pages 14 and 15), or visit epa.gov/lead, or call 1-800-424-LEAD.

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Renovating, Repairing or Painting a Home with Lead-Based Paint

If you hire a contractor to conduct renovation, repair, or painting (RRP) projects in your pre-1978 home or childcare facility (such as pre-school and kindergarten), your contractor must:

• Be a Lead-Safe Certified firm approved by EPA or an EPA-authorized state program

• Use qualified trained individuals (Lead-Safe Certified renovators) who follow specific lead-safe work practices to prevent lead contamination

• Provide a copy of EPA’s lead hazard information document, The Lead-Safe Certified Guide to Renovate Right

RRP contractors working in pre-1978 homes and childcare facilities must follow lead-safe work practices that:

• Contain the work area. The area must be contained so that dust and debris do not escape from the work area. Warning signs must be put up, and plastic or other impermeable material and tape must be used.

• Avoid renovation methods that generate large amounts of lead-contaminated dust. Some methods generate so much lead-contaminated dust that their use is prohibited. They are:

• Open-flame burning or torching

• Sanding, grinding, planing, needle gunning, or blasting with power tools and equipment not equipped with a shroud and HEPA vacuum attachment

• Using a heat gun at temperatures greater than 1100°F

• Clean up thoroughly. The work area should be cleaned up daily. When all the work is done, the area must be cleaned up using special cleaning methods.

• Dispose of waste properly. Collect and seal waste in a heavy duty bag or sheeting. When transported, ensure that waste is contained to prevent release of dust and debris.

To learn more about EPA’s requirements for RRP projects, visit epa.gov/getleadsafe, or read The Lead-Safe Certified Guide to Renovate Right.

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Other Sources of Lead

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Lead in Drinking Water

The most common sources of lead in drinking water are lead pipes, faucets, and fixtures.

Lead pipes are more likely to be found in older cities and homes built before 1986.

You can’t smell or taste lead in drinking water.

To find out for certain if you have lead in drinking water, have your water tested.

Remember older homes with a private well can also have plumbing materials that contain lead.

Important Steps You Can Take to Reduce Lead in Drinking Water

• Use only cold water for drinking, cooking and making baby formula. Remember, boiling water does not remove lead from water.

• Before drinking, flush your home’s pipes by running the tap, taking a shower, doing laundry, or doing a load of dishes.

• Regularly clean your faucet’s screen (also known as an aerator).

• If you use a filter certified to remove lead, don’t forget to read the directions to learn when to change the cartridge. Using a filter after it has expired can make it less effective at removing lead.

Contact your water company to determine if the pipe that connects your home to the water main (called a service line) is made from lead. Your area’s water company can also provide information about the lead levels in your system’s drinking water.

For more information about lead in drinking water, please contact EPA’s Safe Drinking Water Hotline at 1-800-426-4791. If you have other questions about lead poisoning prevention, call 1-800 424-LEAD.*

Call your local health department or water company to find out about testing your water, or visit epa.gov/safewater for EPA’s lead in drinking water information. Some states or utilities offer programs to pay for water testing for residents. Contact your state or local water company to learn more.

* Hearing- or speech-challenged individuals may access this number through TTY by calling the Federal Relay Service at 1-800-877-8339.

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Other Sources of Lead, continued

• Lead smelters or other industries that release lead into the air.

• Your job. If you work with lead, you could bring it home on your body or clothes. Shower and change clothes before coming home. Launder your work clothes separately from the rest of your family’s clothes.

• Hobbies that use lead, such as making pottery or stained glass, or refinishing furniture. Call your local health department for information about hobbies that may use lead.

• Old toys and furniture may have been painted with lead-containing paint. Older toys and other children’s products may have parts that contain lead.4

• Food and liquids cooked or stored in lead crystal or lead-glazed pottery or porcelain may contain lead.

• Folk remedies, such as “greta” and “azarcon,” used to treat an upset stomach.

4 In 1978, the federal government banned toys, other children’s products, and furniture with lead-containing paint. In 2008, the federal government banned lead in most children’s products. The federal government currently bans lead in excess of 100 ppm by weight in most children’s products.

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For More Information

The National Lead Information Center Learn how to protect children from lead poisoning and get other information about lead hazards on the Web at epa.gov/lead and hud.gov/lead, or call 1-800-424-LEAD (5323).

EPA’s Safe Drinking Water Hotline For information about lead in drinking water, call 1-800-426-4791, or visit epa.gov/safewater for information about lead in drinking water.

Consumer Product Safety Commission (CPSC) Hotline For information on lead in toys and other consumer products, or to report an unsafe consumer product or a product-related injury, call 1-800-638-2772, or visit CPSC’s website at cpsc.gov or saferproducts.gov.

State and Local Health and Environmental Agencies Some states, tribes, and cities have their own rules related to lead-based paint. Check with your local agency to see which laws apply to you. Most agencies can also provide information on finding a lead abatement firm in your area, and on possible sources of financial aid for reducing lead hazards. Receive up-to-date address and phone information for your state or local contacts on the Web at epa.gov/lead, or contact the National Lead Information Center at 1-800-424-LEAD.

Hearing- or speech-challenged individuals may access any of the phone numbers in this brochure through TTY by calling the toll-free Federal Relay Service at 1-800-877-8339.

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U. S. Environmental Protection Agency (EPA)Regional Offices

The mission of EPA is to protect human health and the environment. Your Regional EPA Office can provide further information regarding regulations and lead protection programs.

Region 1 (Connecticut, Massachusetts, Maine, New Hampshire, Rhode Island, Vermont)

Regional Lead Contact U.S. EPA Region 1 5 Post Office Square, Suite 100, OES 05-4 Boston, MA 02109-3912 (888) 372-7341

Region 2 (New Jersey, New York, Puerto Rico, Virgin Islands)

Regional Lead Contact U.S. EPA Region 2 2890 Woodbridge Avenue Building 205, Mail Stop 225 Edison, NJ 08837-3679 (732) 321-6671

Region 3 (Delaware, Maryland, Pennsylvania, Virginia, DC, West Virginia)

Regional Lead Contact U.S. EPA Region 3 1650 Arch Street Philadelphia, PA 19103 (215) 814-2088

Region 4 (Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, Tennessee)

Regional Lead Contact U.S. EPA Region 4 AFC Tower, 12th Floor, Air, Pesticides & Toxics 61 Forsyth Street, SW Atlanta, GA 30303 (404) 562-8998

Region 5 (Illinois, Indiana, Michigan, Minnesota, Ohio, Wisconsin)

Regional Lead Contact U.S. EPA Region 5 (DT-8J) 77 West Jackson BoulevardChicago, IL 60604-3666 (312) 886-7836

Region 6 (Arkansas, Louisiana, New Mexico, Oklahoma, Texas, and 66 Tribes)

Regional Lead Contact U.S. EPA Region 6 1445 Ross Avenue, 12th Floor Dallas, TX 75202-2733 (214) 665-2704

Region 7 (Iowa, Kansas, Missouri, Nebraska)

Regional Lead Contact U.S. EPA Region 7 11201 Renner Blvd. WWPD/TOPE Lenexa, KS 66219 (800) 223-0425

Region 8 (Colorado, Montana, North Dakota, South Dakota, Utah, Wyoming)

Regional Lead Contact U.S. EPA Region 8 1595 Wynkoop St. Denver, CO 80202 (303) 312-6966

Region 9 (Arizona, California, Hawaii, Nevada)

Regional Lead Contact U.S. EPA Region 9 (CMD-4-2) 75 Hawthorne Street San Francisco, CA 94105 (415) 947-4280

Region 10 (Alaska, Idaho, Oregon, Washington)

Regional Lead Contact U.S. EPA Region 10 Solid Waste & Toxics Unit (WCM-128) 1200 Sixth Avenue, Suite 900 Seattle, WA 98101 (206) 553-1200

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Consumer Product Safety Commission (CPSC)

The CPSC protects the public against unreasonable risk of injury from consumer products through education, safety standards activities, and enforcement. Contact CPSC for further information regarding consumer product safety and regulations.

CPSC 4330 East West Highway Bethesda, MD 20814-4421 1-800-638-2772 cpsc.gov or saferproducts.gov

U. S. Department of Housing and Urban Development (HUD)

This document is in the public domain. It may be produced by an individual or organization without permission. Information provided in this booklet is based upon current scientific and technical understanding of the issues presented and is reflective of the jurisdictional boundaries established by the statutes governing the co-authoring agencies. Following the advice given will not necessarily provide complete protection in all situations or against all health hazards that can be caused by lead exposure.

EPA-747-K-12-001 U. S. EPA Washington DC 20460 U. S. CPSC Bethesda MD 20814 U. S. HUD Washington DC 20410

HUD’s mission is to create strong, sustainable, inclusive communities and quality affordable homes for all. Contact HUD’s Office of Healthy Homes and Lead Hazard Control for further information regarding the Lead Safe Housing Rule, which protects families in pre-1978 assisted housing, and for the lead hazard control and research grant programs.

HUD 451 Seventh Street, SW, Room 8236 Washington, DC 20410-3000 (202) 402-7698 hud.gov/offices/lead/

June 2017

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IMPORTANT!Lead From Paint, Dust, and Soil in and Around Your Home Can Be Dangerous if

Not Managed Properly

• Children under 6 years old are most at risk for lead poisoning in your home.

• Lead exposure can harm young children and babies even before they are born.

• Homes, schools, and child care facilities built before 1978 are likely to contain lead-based paint.

• Even children who seem healthy may have dangerous levels of lead in their bodies.

• Disturbing surfaces with lead-based paint or removing lead-based paint improperly can increase the danger to your family.

• People can get lead into their bodies by breathing or swallowing lead dust, or by eating soil or paint chips containing lead.

• People have many options for reducing lead hazards. Generally, lead-based paint that is in good condition is not a hazard (see page 10).