Missouri
Department
of
Health
and
Senior
Services
P.
O.
Box
570,
Jefferson
City,
MO
65102­
0570
Phone:
573­
751­
6400
FAX:
573­
751­
6010
RELAY
MISSOURI
for
Hearing
and
Speech
Impaired
1­
800­
735­
2966
VOICE
1­
800­
735­
2466
Richard
C.
Dunn
Director
Bob
Holden
Governor
www.
dhss.
state.
mo.
us
The
Missouri
Department
of
Health
and
Senior
Services
protects
and
promotes
quality
of
life
and
health
for
all
Missourians
by
developing
and
implementing
programs
and
systems
that
provide:
information
and
education,
effective
regulation
and
oversight,
quality
services,
and
surveillance
of
diseases
and
conditions.

AN
EQUAL
OPPORTUNITY
/
AFFIRMATIVE
ACTION
EMPLOYER:
Services
provided
on
a
nondiscriminatory
basis.
Coded
Landlord/
Agent
Identification:
_________________

RESIDENTAL
LEAD
BASED
PAINT
DISCLOSURE
RULE
SITE
VISIT
CHECKLIST
Interviewing
the
Landlord/
Agent
(
Check
one
box
for
each
question)
Yes
No
1.
Are
you
familiar
with
the
lead
based
paint
Disclosure
Rule?

2.
Do
you
provide
the
pamphlet
"
Protect
Your
Family
from
Lead
in
Your
Home"
to
tenants
before
they
sign
a
lease?

3.
Do
you
have
any
letters,
records,
or
reports
regarding
lead­
based
paint
inspections?

If
yes,
did
you
give
the
tenant
a
copy
of
such
documents?
4.
What
would
you
consider
the
best
way
to
provide
outreach
and
education
to
landlords
in
the
St.
Louis
area?

5.
How
would
you
improve
the
"
Disclosure
Rule"
handouts
to
make
them
easier
or
more
understandable
to
a
landlord
and/
or
tenant?

Reviewing
Landlord/
Agent
Records
(
Check
one
box
for
each
question)
Yes
No
1.
Does
the
lease
agreement
include
the
"
lead
warning
statement"?
Housing
built
before
1978
may
contain
lead­
based
paint.
Lead
from
paint,
paint
chips
and
dust
can
pose
health
hazards
if
not
managed
properly.
Lead
exposure
is
especially
harmful
to
young
children
and
pregnant
women.
Before
renting
pre
1978
housing,
lessors
must
disclose
the
presence
of
lead­
based
paint
and/
or
lead­
based
paint
hazards
in
the
dwelling.
Lessees
must
also
receive
a
federally
approved
pamphlet
on
lead
poisoning
prevention.

2.
Does
the
file
include
a
lead­
based
paint
disclosure
form
or
section
of
the
lease?

If
no,
is
the
landlord
aware
that
he
must
provide
these
upon
lease?

3.
Are
there
records
that
indicate
a
lead
based
paint
inspection?

If
yes,
were
these
records
disclosed
to
the
tenant?

Are
the
records
listed
in
the
disclosure
section?

4.
Did
the
tenant
acknowledge,
by
dated
initial
or
signature,
receipt
of:
a)
Pamphlet?

b)
Reports
of
lead
based
paint
inspections
and
results?

c)
Disclosure
form?

5.
Was
disclosure
form
signed
and
dated
by
landlord
and/
or
agent?
Missouri
Department
of
Health
and
Senior
Services
P.
O.
Box
570,
Jefferson
City,
MO
65102­
0570
Phone:
573­
751­
6400
FAX:
573­
751­
6010
RELAY
MISSOURI
for
Hearing
and
Speech
Impaired
1­
800­
735­
2966
VOICE
1­
800­
735­
2466
Richard
C.
Dunn
Director
Bob
Holden
Governor
www.
dhss.
state.
mo.
us
The
Missouri
Department
of
Health
and
Senior
Services
protects
and
promotes
quality
of
life
and
health
for
all
Missourians
by
developing
and
implementing
programs
and
systems
that
provide:
information
and
education,
effective
regulation
and
oversight,
quality
services,
and
surveillance
of
diseases
and
conditions.

AN
EQUAL
OPPORTUNITY
/
AFFIRMATIVE
ACTION
EMPLOYER:
Services
provided
on
a
nondiscriminatory
basis.
Coded
Tenant
Identification:
_________________

RESIDENTAL
LEAD
BASED
PAINT
DISCLOSURE
RULE
SITE
VISIT
CHECKLIST
Interviewing
the
Tenant/
Lessee
(
Check
one
box
for
each
question)
Yes
No
N/
A
1.
Did
you
receive
the
"
Protect
Your
Family
from
Lead
in
Your
Home"
pamphlet
from
your
landlord
before
signing
the
lease?

1.
Did
you
read
the
pamphlet
upon
receipt?

3.
Did
you
make
any
changes
as
described
in
the
pamphlet?

4.
If
no
changes
have
been
made,
why?
(
ex.
no
money,
or
time,
no
supplies,
no
perceived
risk,
no
lead
hazards
at
property).

5.
What
have
you
learned
from
the
educational
information
that
you
received?

6.
Do
you
have
any
suggestions
for
improving
the
educational
information
that
you
received?

7.
Where
do
you
hear
most
of
your
information
about
lead
poisoning?

8.
Has
your
child
received
a
blood
lead
test
within
the
past
year?
(
note:
This
is
not
a
required
answer)
If
not,
please
refer
family
to
the
Health
Department
or
their
Health
care
Provider.
