LEAD PAINT ASSESSMENT

Consent to Enter Property and Take Samples

This is a request for the AGENCYto assess the following property for lead hazards:

ADDRESS: ______

CITY/COUNTY:______

I agree to provide full access to the entire premises, both interior and exterior, to the health department, its agents, employees, and representatives for the purpose of the assessment. This access includes any and all other buildings, structures, and fixtures located on the subject property. In the event that a return visit is necessary for additional assessment, I agree to provide full access to the property at that time. Additionally, I agree to fully cooperate with the AGENCY staff during the assessment.

The site visit may involve taking lead analyzer readings on paint and other household items and dust and soil samples for testing. None of the testing is destructive to the tested surfaces. I understand that it will be necessary for suspected lead hazards and the property in general to be photographed and/or videotaped. A return visit may be needed to do additional lead testing, photographing, and/or videotaping of the area.

I understand that a report will be written and a copy of the report will be provided to me and the owner of the property, if not the same person. The report is also considered a public record and is, therefore, subject to disclosure by the AGENCY upon request, with the following information removed prior to release: property owner, tenants, property address, telephone numbers, and any information that could be used to identify children with lead poisoning living in the home.

In order to provide the best care for the child, I give permission to release related information gathered and/or reports generated as a result of this assessment to local health department staff, the child’s health care providers, and/or the local housing authority.

I have a legal interest in the subject property, either as an owner, lessee, renter, or by some other legal interest, and possess the legal right and authority to permit the above-described assessment. I have sought and obtained permission from all necessary parties and/or entities, if necessary, and I have their authority to permit the assessment.

Parent

Owner

Guardian

Renter

______

SIGNATURE DATE

Revision 03/2015