0923-0048 Form 100

Appendix I1.

Form Approved

OMB No. 0923-0048 Exp. Date 06/30/2022

FORM 100

ATSDR estimates the average public reporting burden for this collection of information as 5 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering, and maintaining the data/information needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB Control Number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0923-0048).

Home Schematic

___________________________

___________________________

Place ID Sticker Here

Inspector and Date

Is this location a: (check one)

☐ Single Family

☐ Mobile Home

☐ Multi Family ≤ 4 units

☐ Multi Family > 4 units

If multi family, what floor is the main occupant entry (basement – 0, ground floor – 1, etc.):

___________

Location has: (check one)

☐ Basement

☐ Slab

☐ Crawlspace

Total number of floors above ground for this residence/building:

___________

Total number of rooms in residence:

___________

Are there any detached painted structures?

☐ YES ☐ NO

Primary exterior covering:

___________

Is primary exterior covering painted?

☐ YES ☐ NO

Primary water source:

☐ Private Well

☐ Public/Rural

☐ Other _________________

1 – Child’s Bedroom

2 – Kitchen

3 – Child’s Play Area

4 – Living Area

Floor number: _______ Floor type: _______ Rug present: ☐ Y ☐ N Condition: _______ Is room also child’s main play area? ☐ Y ☐ N Comments:

Floor number: _______ Floor type: _______ Rug present: ☐ Y ☐ N Condition: _______ Is room also child’s main play area? ☐ Y ☐ N Comments:

Floor number: _______ Floor type: _______ Rug present: ☐ Y ☐ N Condition: _______ Is room also child’s main play area? ☐ Y ☐ N Comments:

Floor number: _______ Floor type: _______ Rug present: ☐ Y ☐ N Condition: _______ Is room also child’s main play area? ☐ Y ☐ N Comments:

• Exterior covering: 1-Wood, 2-Brick, 3-Cement Block, 4-Vinyl/Metal Siding, 5-Other (specify)

• Floor type: 1-Wood, 2-Linoleum, 3-Ceramic Tile, 4-Wall-to-Wall Carpet

• General Condition (scale 1-5): 1-very neat, uncluttered, no dust/soiling – 5-very messy, cluttered, dusty/soiled