New Jersey Department of Community Affairs Division of Housing and Community Resources

NEW JERSEY DEPARTMENT OF COMMUNITY AFFAIRS DIVISION OF HOUSING AND COMMUNITY RESOURCES

New Jersey Weatherization Assistance Program

Home Health & Safety Assessment / Notice of Observed Hazards

Client Name:______File ID:______Date of Assessment: / /

Address:______Year Built:______
Housing Type: Single Family / Manufactured / Townhome / Low-Rise Multifamily / Four-Plus Story

Exterior Site/Building Inspection
Issue/Hazard
Estimated Costs / Description/Location/Severity / Necessary Correction (Common Corrections Noted)
& Relationship to Wx Work / Cause for Deferral?
Referral Options
Structural & Roofing (Costs in package SIR as Incidental Repair) / Minor corrections performed as incidental repair. / No / Yes
Potential Asbestos Siding - Surface & Subsurface (Costs included w/ ECM) / Remove/replace w/ ECM costs. Assure minimal breakage w/ proper containment & disposal. Inform client that suspected asbestos siding is present and how precautions will be taken for containment and to ensure minimal breakage of siding. / No / Yes
Moisture Intrusion/ Site Drainage/ Gutters/Other
$______/ Moderate/severe moisture conditions must be corrected or the unit deferred. Mold cleaning not allowed. / No / Yes
Pest Intrusion Prevention/ Removal
$______/ Only if preventing Wx or potential for damage to installed measures. Intrusion prevention measures allowed. / No / Yes
Suspected Paint Containing Lead (pre 1978)
$______/ Use LSW & RRP if disturbing potential lead. / No / Yes
Other
$______/ No / Yes
Mechanical/Appliance Inspection
Issue/Hazard
Estimated Costs / Description/Location/Severity / Necessary Correction (Common Corrections Noted)
& Relationship to Wx Work / Cause for Deferral?
Referral Options
Heating (CO, Moisture, Electrical, Gas, Operation)
If DOE WAP:
$______/ Use LIHEAP protocols. / Corrections w/ LIHEAP. If WAP, must attempt as ECM before H&S funds. / No / Yes
Cooling (Moisture, Electrical)
If DOE WAP:
$______/ Use LIHEAP protocols. / Corrections w/ LIHEAP only to facilitate heating or medical condition w/ Dr.’s note. If WAP, must attempt as ECM before H&S funds. / No / Yes
Water Heater (CO, Moisture, Electrical, Gas, Operation)
If DOE WAP:
$______/ Use LIHEAP protocols. / Corrections w/ LIHEAP. If WAP, must attempt as ECM before H&S funds. / No / Yes
Ventilation (Attic, Basement, Local, Dryer, Whole House)
$______/ Complete ASHRAE Checklist & Pre-Weatherization CFM:
Whole House:______
Kitchen:______
Bath:______Location:______
Bath:______Location:______
Other:______/ Proper venting required. Seal & vent exhaust ducts to outside w/ shortest run. Assure kitchen has operable 100 CFM tested fan, full baths a 50 CFM tested fan, or meet ASHRAE 62.2 whole house calculation. Whole house ontinuous exhaust system required in Tier 1 radon municipalities and recommended in Tier 2. Defer when high moisture/pollutants are present & cannot mitigate. / No / Yes
Space Heater Removal
$______/ Remove & dispose of unvented space heaters. ANSI A21.11.2 labeled secondary units okay. Electric heater removal recommended. / No / Yes
Other
$______/ No / Yes
Basement/Crawlspace Inspection
Issue/Hazard
Estimated Costs / Description/Location/Severity / Necessary Correction (Common Corrections Noted)
& Relationship to Wx Work / Cause for Deferral?
Referral Options
Structural (Costs in package SIR as Incidental Repair) / Minor corrections performed as incidental repairs. / No / Yes
Return Ducts (if not sealed as ECM)
$______/ Seal return ducts if CO, pollutants, or moisture present. / No / Yes
Electrical/Fire Hazard (if not w/ ECM)
$______/ Include w/ LIHEAP or ECM costs when a component of a measure. Correct with H&S if necessary to perform Wx. / No / Yes
Potential Friable Asbestos (Removal or Encapsulation)
$______/ DO NOT DISTURB. Test & correction by AHERA professional only. Charged w/ LIHEAP if part of related furnace work. Friable asbestos must be corrected or the unit deferred. / No / Yes
Mold & Moisture and Biological Conditions
$______/ Moderate/severe moisture & biological conditions must be corrected or the unit deferred. Mold cleaning not allowed. / No / Yes
Exposed Dirt
$______/ Install sealed vapor barrier where site conditions permit. Optional for mobile homes. / No / Yes
Clutter/Access
$______/ Perform removal or correction necessary to allow access for effective Wx. / No / Yes
Other
$______/ No / Yes
Attic Inspection
Issue/Hazard
Estimated Costs / Description/Location/Severity / Necessary Correction (Common Corrections Noted)
& Relationship to Wx Work / Cause for Deferral?
Referral Options
Structural (Costs in package SIR as incidental repair) / Minor corrections performed as incidental repairs. / No / Yes
Potential Asbestos – Vermiculite (No corrections allowed, testing required) / DO NOT DISTURB. Do not perform blower door tests or additional attic assessment once observed. Requires AHERA testing before any work. If positive for asbestos in Vermiculite the unit must be deferred. / No / Yes
Return Ducts (if not sealed as ECM)
$______/ Seal return ducts if CO, pollutants, or moisture present. / No / Yes
Electrical/Knob & Tube/Fire Hazard (if not w/ ECM)
$______/ Include w/ LIHEAP or ECM costs when a component of a measure. Correct with H&S if necessary to perform Wx. / No / Yes
Mold & Moisture and Biological Conditions
$______/ Moderate/severe moisture & biological conditions must be corrected or the unit deferred. Mold cleaning not allowed. / No / Yes
Clutter/Access
$______/ Perform removal or correction necessary to allow access for effective Wx. / No / Yes
Other
$______/ No / Yes
Garage/Storage Inspection
Issue/Hazard
Estimated Costs / Description/Location/Severity / Necessary Correction (Common Corrections Noted)
& Relationship to Wx Work / Cause for Deferral?
Referral Options
Garage Air Intrusion (if not sealed as ECM)
$______/ Seal all penetrations between garage and living space. / No / Yes
Return Ducts (if not sealed as ECM)
$______/ Seal return ducts if CO, pollutants, or moisture present and not meeting SIR. / No / Yes
Electrical/Fire Hazard (if not w/ ECM)
$______/ Include w/ LIHEAP or ECM costs when a component of a measure. Correct with H&S if necessary to perform Wx. / No / Yes
Hazardous Chemicals/VOCs
$______/ High concentrations of hazardous chemicals must be removed from the living space or the unit deferred. / No / Yes
Clutter/Access
$______/ Perform removal or correction necessary to allow access for effective Wx. / No / Yes
Other
$______/ No / Yes
Interior/Conditioned Space Inspection
Issue/Hazard
Estimated Costs / Description/Location/Severity / Necessary Correction (Common Corrections Noted)
& Relationship to Wx Work / Cause for Deferral?
Referral Options
Structural (Costs in package SIR as incidental repair) / Performed as incidental repairs and must fall within the package SIR or defer unit. / No / Yes
Electrical/Fire Hazard (if not w/ ECM)
$______/ Include w/ LIHEAP or ECM costs when a component of a measure. Correct with H&S if necessary to perform Wx. / No / Yes
Mold & Moisture and Biological
Conditions
$______/ Moderate to severe moisture & biological creating conditions must be corrected or the unit deferred. Mold cleaning not allowed. / No / Yes
Clutter/Access
$______/ Perform removal or correction necessary to allow access for effective Wx. / No / Yes
Suspected Paint Containing Lead (pre 1978)
$______/ Use Lead Safe Work practices and follow RRP requirements where Wx will disturb suspected lead paint. / No / Yes
Smoke/CO Alarm Installation or Fire Extinguisher
$______/ Install alarms where not present, functioning, or within their useful life. Extinguisher for when Wx impacts solid fuel heat. / No / Yes
Other
$______/ No / Yes
Health & Safety Assessment/Testing
Assessments & Tests w/ Cost & Signature of Tester (include results documentation w/ client file and provide copies to client) / Test Results / Cause for Deferral?
Referral Options
$______H&S Assessment (required)______
$______Combustion Safety (conditional)______
$______ASHRAE 62.2 (conditional)______
$______Radon (conditional)______
$______Asbestos (conditional)______
$______Lead (optional)______
$______Moisture (optional)______
$______Voltage/Electrical (optional)______
$______Other (explain)______ / No / Yes
Deferral Based On Unreasonable Health & Safety Costs
Total estimated DOE WAP cost of necessary & allowed
Health and Safety (Assessments, Testing, Corrections, Etc.) / $ / Program Operations (ECMs, Audit, Incidental, Etc.) Note: this does not include Health & Safety Costs / $
Costs for correcting Health & Safety cannot exceed $1,300 without DCA Program Supervisor Approval. Costs between $650 and $1,300 must be approved by a State Program Monitor. / Percent
(Health & Safety costs divided by unit cost for Program Operations): / %
State Signature for Approval of H&S Costs at or above $650 (or include written approval) :

Not all health and safety conditions prevent weatherization (Wx) work. Only health and safety corrections necessary for Wx to proceed or to prevent worsening existing conditions as a result of Wx activity can be addressed with WAP funds and must be within reasonable costs. The New Jersey WAP is not responsible for correcting preexisting conditions in the home and deferral may be necessary; however, it is expected that the local agency makes efforts to identify assistance where WAP funds cannot be used to correct health and safety conditions. Use the www.wxplushealth.org “Find a Provider” tool to locate potential resources in your area.

I have been advised of the above observed health and safety conditions and understand that this assessment is preliminary and does not necessarily reflect all of the health and safety concerns within my home, actual costs of correction, or the severity of the condition.

/ /

Client’s Printed Name Client’s Signature Date

Please contact your local WAP agency if you have any questions or concerns about the work being performed in your home.

(Include Auditor Contact, Address, Email, and Phone Number)

Vol 1. October 2, 2013 Page 2