Information
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Document No.
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Audit Title
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
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Sample Pre-Renovation Form
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This sample form may be used by renovation firms to document compliance with the Federal pre-renovation education and renovation, repair, and painting regulations.
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Occupant Confirmation
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Pamphlet Receipt
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I have received a copy of the lead hazard information pamphlet informing me of the lead hazard exposure from renovation activity to be performed in my dwelling unit. I received this pamphlet before the work began.
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Printed name of owner-occupant
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Signature of Owner-occupant
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Signature Date
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Renovator's Self Certification Option (For tenant-occupied dwellings only) Instructions to Renovator: If the lead hazard information pamphlet was delivered but a tenant signature was not attainable, you may check the appropriate box below.
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Declined - I certify that I have made a good faith effort to deliver the lead hazard information pamphlet to the rental dwelling unit listed below at the date and time indicated and that the occupant declined to sign the confirmation of receipt. I further certify that I have left a copy of the pamphlet at the unit with the occupant.
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Unavailable for signature - I certify that I have made a good faith effort to deliver the lead hazard information pamphlet to the rental dwelling unit listed below and that the occupant was unavailable to sign the confirmation of receipt. I further certify that I have left a copy of the pamphlet at the unit by sliding it under the door or by (fill in how the pamphlet was left)
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Printed name of person certifying delivery
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Attempted delivery date
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Signature of person certifying lead pamphlet delivery
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Note regarding mailing option - as an alternative to delivery in person, you may mail the lead hazard information pamphlet to the owner and/or tenant. Pamphlet must be mailed at least seven days before renovation. Mailing must be documented by a certificate of mailing from post office.
