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.







*Home Built Before 1978?
Yes | No
*Home Currently Vacant?
Yes | No
*Owner - Occupied?
Yes | No
*Renter-Occupided?
Yes | No


*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

Does Anyone At The Home Have An Elevated Blood Lead Level Yes or No?
Yes | No

Do You Give DHCD Permission To Share Your Information With Your Local Program Provider?
Yes | No
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