Lead Hazard Reduction Program Referral Form
Lead Hazard Reduction Program Referral Form
Submit Referral
Referral Submission Steps:
All fields marked With * Are required for submissions. Click Please Note: Fields marked with + are required if owner information is is not the same as applicant's
Please Note: Most questions can be answered with Yes Or No. Some questions may require you it enter in longer form answers.
When form is complete please sumbit it to DHCD by clicking the Sumbit Button.
If you have an questions please contact: DHCD LHR Program.
Fields Marked With
*
Are Required For Referral Submission
Applicant Information:
Property Questions And Information:
Please Answer The Questions Below With Yes or No
*Home Built Before 1978?
Yes
| No
*Home Currently Vacant?
Yes
| No
*Owner - Occupied?
Yes
| No
*Renter-Occupided?
Yes
| No
(+Please Complete If Different From Above) Property Owner Information:
Home And Occupancy Questions And Information:
*
Click Yes if any of the following apply:
Child Under 6 Living Or Visiting The Home Twice A Week? |Is There A Pregnant Woman Living At The Home?
Yes
| No
Medical Questions And Information:
Does Anyone At The Home Have An Elevated Blood Lead Level Yes or No?
Yes
| No
Consent And Permission:
Do You Give DHCD Permission To Share Your Information With Your Local Program Provider?
Yes
| No
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