Form F 00201 – Fill Out and Use This PDF

DEPARTMENT OF HEALTH SERVICES	STATE OF WISCONSIN
Division of Public Health	Bureau of Environmental and Occupational Health
F-00201 (12/09)	DHS 163, Wis. Adm. Code

OCCUPANT PROTECTION PLAN

Checklist for Lead-Based Paint Activities

1.For all regulated lead-based paint activities, complete an Occupant Protection Plan and keep it at the job site for viewing by interested persons.

2.When restricted work practices will be used in conducting any regulated lead-based paint activity:

Provide the Occupant Protection Plan to the property owner and all occupied dwelling units with direct access to work areas at least 2 days before starting the activity.

Deliver the document and keep a signed copy for company records.

The Occupant Protection Plan can be delivered to each dwelling unit by mail if sent by certified mail at least 7 days before the start of this activity.

Name of Occupant(s) (List property owner’s name if unit is not occupied)

Address	Unit Number (if applicable)
City		Zip
	WI
Lead Contractor Name	DHS Certification Number	Contractor Telephone Number
		(	)
Project Date(s) (mm/dd/yy)

OCCUPANT PROTECTION PLAN CHECKLIST FOR LEAD-BASED PAINT ACTIVITIES

This is a checklist of actions the contractor will take to protect the occupant, while paint is disturbed. Occupants must stay out of work areas while work is in progress. The contractor will do daily clean-ups, but the work area may still contain dangerous levels of dust- lead. Unless otherwise noted, work will be done by the contractor.

Occupant Location (Check all that apply)

Unit is vacant (no movable objects remain in the unit; i.e. stove, refrigerator).

Occupants will be relocated and out of the unit until the lead project is done.

Occupants will not be allowed within the work area before project completion, including clearance with documented dust wipe sample results.

Occupants will not be allowed within the work area before project completion, including mandatory visual clearance.

Occupants will be outside the dwelling during work times but may return each day after clean up.

Occupants will have lead-safe passage to bathroom, living area, and entry/exit door during the project.

Occupants will be provided a lead-safe entry and exit pathway during the project. Occupants pets will not be allowed in the work area.

Furniture (Check all that apply)

Will inform Occupant(s) to remove all personal items and as much furniture as possible from work area before work begins. Will cover with plastic all furniture and personal belongings that cannot be removed.

Containment and Barrier System (Check all that apply)

Interior Work

Will use a dust room for work on removable components such as windows and doors.

Will use an airlock flap on all doorways to work areas (Z-flap), or will close and secure doors from inside the work site. Will use plastic to cover entire floor, all worker pathways to exit and any workrooms.

Will use plastic to cover floor extending 5 feet beyond work area in all directions and where it is practical. Workers will stay on plastic.

Will inform Occupants to keep off of plastic in work area.

Will lock or firmly secure work area to provide an overnight barrier.

Will post warning signs at entry to each room where work is being done, or will post warning signs on the building exterior near main and secondary entryways.

Exterior Work (Containment and Barrier System continued)

Will remove all movable items (playground equipment, toys, sandbox, patio furniture, etc.) to a distance of 20 feet from work area or seal these items with plastic and tape.

Will use plastic sheeting or landscape fabric on the ground extending 10 feet from building, where practical. Will keep all windows, including windows of adjacent dwellings, within 20 feet of work closed.

Will erect barrier tape or temporary fencing to make a 20-foot perimeter around building. Will post warning signs on the building exterior near all entryways.

F-00201 (12/09) Page 2

Exterior Work (Containment and Barrier System continued)

Will remove all movable items (playground equipment, toys, sandbox, patio furniture, etc.) to a distance of 20 feet from work area or seal these items with plastic and tape.

Will use plastic sheeting or landscape fabric on the ground extending 10 feet from building, where practical. Will keep all windows, including windows of adjacent dwellings, within 20 feet of work closed.

Will erect barrier tape or temporary fencing to make a 20-foot perimeter around building. Will post warning signs on the building exterior near all entryways.

Window Work

Will tape plastic to exterior wall when removing windows from the inside.

Will tape plastic to interior wall when removing windows from the outside.

Will use plastic sheeting or landscape fabric on the ground under the windows.

Restricted Work Practices (Check all that apply)

Will use a heat gun, not to exceed 1100 degrees Fahrenheit.

Will use machine planer, chipper, grinder, or sander that is attached to a properly operating HEPA-filtered vacuum. Will use proper containment while using any of these machines.

Will use chemical paint stripper to remove lead-based paint from components and will follow manufacturer instructions. Will use power washing or hydro-blasting. Will use proper containment to prevent the waste generated from contaminating soils or surface waters.

Will remove components such as complete door systems, siding, walls, cabinets or trim. Will use containment to isolate areas where paint is being disturbed from the rest of the property.

Will use abrasive blasting or sandblasting. Will use containment to isolate areas where paint is being disturbed from the rest of the property while using either of these practices.

Ventilation System (Check all that apply)

Will turn off system and seal all vents in workroom with plastic.

Will turn off system and seal off vents within 5 feet of the work area.

Daily Cleaning (Check all that apply)

Will remove debris from dwelling or store it in a locked secure area.

Will clean all horizontal surfaces in the work areas with a HEPA vacuum and wet washed. Will clean and remove plastic walkways each day.

Will clean all walkways that are used as pathways to the work area with a HEPA vacuum. Will clean if containment is breached on both sides of the containment.

Will clean off debris, fold, and secure all plastic sheeting or landscape fabric overnight but may use again the next day.

Final Cleaning (Check all that apply)

Will remove all debris and visible dust.

Will HEPA vacuum; wet wash and HEPA vacuum all horizontal surfaces and trim in work areas.

Will HEPA vacuum, wet wash, and HEPA vacuum all surfaces and floors extending at least 5 feet in all directions from treated surface.

LEAD CERTIFIED CONTRACTOR

I certify that a copy of the Occupant Protection Plan was provided to the property owner or occupant(s) of the property address listed on this form on this date __________________________ by way of ______________________________ (describe delivery method).

SIGNATURE – Certified Lead Contractor		Date Signed (mm/dd/yy)
For more information, contact the Asbestos and Lead Section at the information below
Mailing Address	Department of Health Services
	Asbestos and Lead Section, Rm 137
	P.O. Box 2659
	Madison WI 53701-2659
Telephone Number	(608) 261-6876
Fax Telephone Number	(608) 266-9711
Website Address	http://dhs.wisconsin.gov/lead