Ohio Hea 5802 Form Modify Form Here

Ohio Hea 5802 Form

The Ohio HEA 5802 form is a monthly summary report required by the Ohio Department of Health for documenting lead inspection, risk assessment, and clearance examination activities. This form must be completed and submitted by the 15th of each month to ensure compliance with state regulations. It is essential to provide accurate information for each property and activity to avoid delays or rejections of the submission.

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Table of Contents

The Ohio HEA 5802 form plays a crucial role in the state's efforts to monitor and manage lead hazards in residential properties. This monthly summary form is designed for licensed lead inspectors, risk assessors, and clearance technicians to report their activities related to lead inspections, risk assessments, and clearance examinations. Each submission must detail activities from the previous month and is due by the 15th of each month. If no activities occurred, the form allows for a simple indication of "no activity." It is essential to complete all sections of the form accurately, as incomplete submissions will be returned. The form requires separate entries for each property and activity, ensuring clarity in reporting. For instance, if a clearance examination fails initially but passes upon reexamination, both outcomes must be documented separately. Additionally, the form includes specific questions about whether a lead hazard was found and whether the property was constructed before 1950, as these factors are critical in assessing lead exposure risks. Submissions can be made via mail, fax, or email, providing flexibility for users. Understanding the HEA 5802 form is vital for maintaining compliance with Ohio's lead poisoning prevention regulations and ensuring the safety of residents.

Form Sample

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 3701-32-15 of the Ohio Administrative Code this monthly summary form shall be completed to report each previous month’s activities. This form should be submitted by the 15th of each month. If there was no activity performed that month, check the “no activity” box.

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) 752-4157

E-mailed to lead@odh.ohio.gov

Name of licensed Lead Inspector / Risk Assessor / Clearance Technician

 

License number

 

 

 

Employer

 

Phone number

 

 

 

Employer address

Email address

 

 

 

 

City

State

ZIP

 

 

 

Month and year of reportable activity (one month per form only)

 

 

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 Non-Abatement

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 Non-Abatement

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 Non-Abatement

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 Non-Abatement

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 Non-Abatement

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 Non-Abatement

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 Non-Abatement

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 Non-Abatement

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 Non-Abatement

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

Form Information

Fact Name Details
Governing Law This form is governed by paragraph (D) of rule 3701-32-15 of the Ohio Administrative Code.
Submission Deadline Submit the completed form by the 15th of each month to report activities from the previous month.
No Activity Reporting If no activities occurred in a month, check the “no activity” box on the form.
Separate Lines for Activities Each property address and activity must be reported on a separate line for clarity.
Indicating Lead Hazards Mark “Yes” if a lead hazard was found during clearance examination; otherwise, mark “No”.
Submission Methods Forms can be sent by mail, fax, or email to the Ohio Department of Health.
Contact Information Include the name, license number, and contact details of the licensed Lead Inspector or Risk Assessor on the form.
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