The Ohio HEA 5802 form serves a critical role in the state's efforts to prevent lead poisoning, a significant health hazard that can have lasting effects, especially in children. Issued by the Ohio Department of Health's Lead Poisoning Prevention Program, this comprehensive document is designed for licensed lead inspectors, risk assessors, and clearance technicians to report their monthly activity. The form, which must be submitted by the 15th of each month, captures a detailed account of activities such as lead inspections, risk assessments, and clearance examinations performed on properties. It distinguishes whether an activity was conducted and if lead hazards were identified or resolved, providing an essential tracking mechanism to ensure that lead risks are assessed and mitigated efficiently. Additionally, the form includes provisions for reporting on various types of activities like abatements, investigations, and renovations, adapting to the wide array of scenarios inspectors may encounter. The meticulous requirement to report each property address and activity separately ensures accuracy and thoroughness in tracking and addressing lead hazards across Ohio.
| Question | Answer |
|---|---|
| Form Name | Ohio Form Hea 5802 |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | hea5802 oh dept of health lead program online monthly summary form |
Ohio Department of Health • Lead Poisoning Prevention Program
Lead Monthly Summary
Page 1 of
Lead Inspection/Risk Assessment/Clearance Examination Activity
1.In accordance with paragraph (D) of rule
2.Please complete all parts of this form. This form will be returned if any information is lacking.
3.Please complete a separate line for each property address and each activity. For example, if you conducted a clearance examination at 111 Main Street and the examination initially failed, but passed upon reexamination, you should enter each examination as a separate line. One line should be completed for the failed examination and one line for the passed examination.
4.You should always indicate “Yes” to the question “Was a lead hazard found” if the property failed clearance examination.
5.You should always indicate “No” to the question “Was a lead hazard found” if the property passed the clearance examination.
6.Monthly summary forms can be submitted by one of the following methods:
•Sent by first class mail to: Ohio Department of Health,
DQA/Lead Program, 246 North High Street, Columbus Ohio, 43215
•Faxed to (614)
•
Name of licensed Lead Inspector / Risk Assessor / Clearance Technician |
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License number |
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Employer |
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Phone number |
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Employer address |
Email address |
|
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City |
State |
ZIP |
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Month and year of reportable activity (one month per form only) |
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A No activity
Summary Information
1. Property address
City
State
OH
ZIP
Was constructed before 1950? |
A Yes |
A No |
Was a lead hazard found? |
A Yes |
A No |
Activity performed select only one per line |
|
Reason for activity |
|
|
|
A Inspection |
A Partial Inspection |
A Abatement |
A |
||
A Risk Assessment |
A Partial Risk Assessment |
A EBL Investigation |
A Lead Safe Renovation |
||
A Lead Hazard Screen |
A Inspection and Risk Assessment |
A Hazard Control Order |
A Essential Maintenance Practices |
||
A Clearance Examination |
|
|
A Owner requested |
|
|
If Clearance was performed, did clearance area pass? A Yes A No
2. Property address
City
State
OH
ZIP
Was constructed before 1950? |
A Yes |
A No |
Was a lead hazard found? |
A Yes |
A No |
Activity performed select only one per line |
|
Reason for activity |
|
|
|
A Inspection |
A Partial Inspection |
A Abatement |
A |
||
A Risk Assessment |
A Partial Risk Assessment |
A EBL Investigation |
A Lead Safe Renovation |
||
A Lead Hazard Screen |
A Inspection and Risk Assessment |
A Hazard Control Order |
A Essential Maintenance Practices |
||
A Clearance Examination |
|
|
A Owner requested |
|
|
If Clearance was performed, did clearance area pass? A Yes A No
3. Property address
City
State
OH
ZIP
Was constructed before 1950? |
A Yes |
A No |
Was a lead hazard found? |
A Yes |
A No |
Activity performed select only one per line |
|
Reason for activity |
|
|
|
A Inspection |
A Partial Inspection |
A Abatement |
A |
||
A Risk Assessment |
A Partial Risk Assessment |
A EBL Investigation |
A Lead Safe Renovation |
||
A Lead Hazard Screen |
A Inspection and Risk Assessment |
A Hazard Control Order |
A Essential Maintenance Practices |
||
A Clearance Examination |
|
|
A Owner requested |
|
|
If Clearance was performed, did clearance area pass? A Yes A No
HEA 5802 7/06
Lead Monthly Summary |
Page _______ of _________ |
|
4. Property address
City
State
OH
ZIP
Was constructed before 1950? |
A Yes |
A No |
Was a lead hazard found? |
A Yes |
A No |
Activity performed select only one per line |
|
Reason for activity |
|
|
|
A Inspection |
A Partial Inspection |
A Abatement |
A |
||
A Risk Assessment |
A Partial Risk Assessment |
A EBL Investigation |
A Lead Safe Renovation |
||
A Lead Hazard Screen |
A Inspection and Risk Assessment |
A Hazard Control Order |
A Essential Maintenance Practices |
||
A Clearance Examination |
|
|
A Owner requested |
|
|
If Clearance was performed, did clearance area pass? A Yes A No
5. Property address
City
State
OH
ZIP
Was constructed before 1950? |
A Yes |
A No |
Was a lead hazard found? |
A Yes |
A No |
Activity performed select only one per line |
|
Reason for activity |
|
|
|
A Inspection |
A Partial Inspection |
A Abatement |
A |
||
A Risk Assessment |
A Partial Risk Assessment |
A EBL Investigation |
A Lead Safe Renovation |
||
A Lead Hazard Screen |
A Inspection and Risk Assessment |
A Hazard Control Order |
A Essential Maintenance Practices |
||
A Clearance Examination |
|
|
A Owner requested |
|
|
If Clearance was performed, did clearance area pass? A Yes A No
6. Property address
City
State
OH
ZIP
Was constructed before 1950? |
A Yes |
A No |
Was a lead hazard found? |
A Yes |
A No |
Activity performed select only one per line |
|
Reason for activity |
|
|
|
A Inspection |
A Partial Inspection |
A Abatement |
A |
||
A Risk Assessment |
A Partial Risk Assessment |
A EBL Investigation |
A Lead Safe Renovation |
||
A Lead Hazard Screen |
A Inspection and Risk Assessment |
A Hazard Control Order |
A Essential Maintenance Practices |
||
A Clearance Examination |
|
|
A Owner requested |
|
|
If Clearance was performed, did clearance area pass? A Yes A No
7. Property address
City
State
OH
ZIP
Was constructed before 1950? |
A Yes |
A No |
Was a lead hazard found? |
A Yes |
A No |
Activity performed select only one per line |
|
Reason for activity |
|
|
|
A Inspection |
A Partial Inspection |
A Abatement |
A |
||
A Risk Assessment |
A Partial Risk Assessment |
A EBL Investigation |
A Lead Safe Renovation |
||
A Lead Hazard Screen |
A Inspection and Risk Assessment |
A Hazard Control Order |
A Essential Maintenance Practices |
||
A Clearance Examination |
|
|
A Owner requested |
|
|
If Clearance was performed, did clearance area pass? A Yes A No
8. Property address
City
State
OH
ZIP
Was constructed before 1950? |
A Yes |
A No |
Was a lead hazard found? |
A Yes |
A No |
Activity performed select only one per line |
|
Reason for activity |
|
|
|
A Inspection |
A Partial Inspection |
A Abatement |
A |
||
A Risk Assessment |
A Partial Risk Assessment |
A EBL Investigation |
A Lead Safe Renovation |
||
A Lead Hazard Screen |
A Inspection and Risk Assessment |
A Hazard Control Order |
A Essential Maintenance Practices |
||
A Clearance Examination |
|
|
A Owner requested |
|
|
If Clearance was performed, did clearance area pass? A Yes A No
9. Property address
City
State
OH
ZIP
Was constructed before 1950? |
A Yes |
A No |
Was a lead hazard found? |
A Yes |
A No |
Activity performed select only one per line |
|
Reason for activity |
|
|
|
A Inspection |
A Partial Inspection |
A Abatement |
A |
||
A Risk Assessment |
A Partial Risk Assessment |
A EBL Investigation |
A Lead Safe Renovation |
||
A Lead Hazard Screen |
A Inspection and Risk Assessment |
A Hazard Control Order |
A Essential Maintenance Practices |
||
A Clearance Examination |
|
|
A Owner requested |
|
|
If Clearance was performed, did clearance area pass? A Yes A No
HEA 5802 7/06