NEW JERSEY DEPARTMENT OF COMMUNITY AFFAIRS
DIVISION OF HOUSING AND COMMUNITY RESOURCE
WEATHERIZATION ASSISTANCE PROGRAM
ASHRAE 62.2 – 2010 Residential Ventilation Standard
Auditor/Inspector Checklist
Client Name:_____________________________________________________ File ID:__________________
Address:__________________________________________________________________________________
Radon Risk Level Area: Tier 1 (testing required) / Tier 2 (testing recommended) / Tier 3 (testing allowed)
Post-Weatherization CFM: Whole House:____Kitchen:____Bath 1:____Bath 2:____Other(______):_______
Check for where items are in place or appropriate corrections made (required items must be checked).
Auditor Inspector Activity
Continuous exhaust ventilation was installed in the home as a radon precaution.
(required in Tier 1 radon municipalities and recommended in Tier 2)
All bathrooms have fans operating at 50 CFM on-demand or 20 CFM continuous
or the alternative compliance path was performed.* (required)
The main kitchen has a fan operating at 100 CFM on-demand or 5ACH based on
kitchen volume or the alternative compliance path was performed.* (required)
If present, whole building fan providing IAQ ventilation air operates
automatically without requiring occupant intervention. (required when present)
All clothes dryers are properly vented to exterior. (required)
If present, adjoining garage(s) are sufficiently air sealed from the living space to
prevent migration of contaminants. (required when present)
If the fan providing the IAQ ventilation air is set to cycle on & off, the entire
on/off cycle is completed within four hours. (required if timed intermittent)
If WAP installed whole building fans, they are rated 1 sone or less. (required if
WAP installed)
If WAP installed local occupant controlled fans, they are rated at 3 sones or less.
(required if WAP installed)
Auditor Printed Name: ________________________________________________________________
Auditor Signature:_________________________________________________Date:
/
/
Inspector Printed Name: _________________________________________________________________
Vol 1. July 17, 2013
Page 1
NEW JERSEY DEPARTMENT OF COMMUNITY AFFAIRS
DIVISION OF HOUSING AND COMMUNITY RESOURCE
Inspector Signature:______________________________________________ Date:
/
/
WEATHERIZATION ASSISTANCE PROGRAM
Lead, Mold, Radon, Asbestos Assessment Determination
Client Name:
File ID:
_
Address:
Year Built:
_
Radon Risk Level Area: Tier 1 (testing required) / Tier 2 (testing recommended) / Tier 3 (testing allowed)
NOTICE: The health and safety of the building, the occupants, or the weatherization staff shall not be compromised by
any retrofit material, technique or practice. To ensure health and safety, relevant assessments will be conducted as part of
all building analysis. Some weatherization activities may reduce the air infiltration on the home and potentially create
higher concentrations of existing pollutants, including but not limited to: radon, carbon monoxide, and formaldehyde.
Some weatherization activities may also create dust or other airborne particles, including but not limited to: insulation,
mold, and lead.
FOR AND IN CONSIDERATION of the State of New Jersey, the New Jersey Department of Community Affairs and
(Insert Subgrantee Agency Name Here), hereafter referred to as the Agency, its agents and employees assisting in the
provision of weatherization services to our dwelling, I/WE DO HEREBY RELEASE the New Jersey, the New Jersey
Department of Community Affairs, and the Agency its agents or employees from any and all liability for losses, damages,
costs, personal injury, death, or other claims because of, or in relation to the installation, location, or malfunction of
measures performed.
It has been determined that this home (check all that apply):
 was built before 1978 and assumed to contain lead-based paint where such areas of the home were disturbed by
weatherization activity and proper lead safe precautions were followed (include Checklist for Lead Safe
Weatherization on dwellings built before 1978 in client file with photo documentation).
 experienced no disturbance of lead-based paint during weatherization activity or the areas of the home directly
impacted by weatherization were free of lead as determined through EPA testing protocols (provide
documentation of test results to client).
 has suspected mold and moisture conditions that are considered minor and proper ventilation and
dehumidification was installed.
 has short-term radon test levels below the EPA action level for radon and precautions were taken to prevent
increasing radon levels, including installed continuous exhaust ventilation, covered expose dirt with a sealed
vapor barrier as site conditions permit, and sealing floor and/or foundation penetrations.
 has suspected asbestos siding and proper containment precautions were followed.
 has suspected friable asbestos and encapsulation and/or removal was performed by an AHERA professional.
 must be deferred for weatherization due to the potential that weatherization activity may exacerbate an existing
pollutant or contaminant (see explanation of deferral on the Client Deferral Notification form).
My signature below denotes that I fully understand the above waiver and its release of liability. I have chosen to go
forward with the weatherization process, accepting any and all risks of injury or damages.
Client Printed Name:
Client Signature:
_
Date:
/
/
Auditor Printed Name: _________________________________________________________________
Auditor Signature: _______________________________________________Date:
Vol 1. July 17, 2013
/
/
Page 2
NEW JERSEY DEPARTMENT OF COMMUNITY AFFAIRS
DIVISION OF HOUSING AND COMMUNITY RESOURCE
(Include Subgrantee Agency Auditor Contact, Address, Email, and Phone Number)
Vol 1. July 17, 2013
Page 3
NEW JERSEY DEPARTMENT OF COMMUNITY AFFAIRS
DIVISION OF HOUSING AND COMMUNITY RESOURCE
WEATHERIZATION ASSISTANCE PROGRAM
Determination of Lead Safe Weatherization (LSW) on dwelling built before 1978.
Client Name:_____________________________________________________ File ID:__________________
Address:_________________________________________________________Year Built:_______________
Date of Assessment:
/
/
Name of Renovator/Company: _______________________________________________________________
Brief Description of Renovation:______________________________________________________________
__________________________________________________________________________________________
Location (Estimated Square Feet of Disturbance): ___ interior (______ft2)
___ exterior (______ft2)

Did the work performed involve the disturbance of painted surfaces 6 square feet or greater for
interior or 20 square feet or greater for exterior or otherwise trigger Lead: Renovation, Repair,
and Painting Program (RRP) rules?
_____ Yes _____No

If lead testing was performed on surfaces to be disturbed by weatherization work triggering EPA
RRP lead rules, were any of the test results positive for lead?
_____ Yes _____No
If the answer to both questions is no, please complete this page and include form in client file.
If the answer to either of the above questions is Yes, please skip to & complete Page 2 of this form.

Did the work performed involve the disturbance of painted surfaces less than 6 square feet for
interior or less than 20 square feet for exterior surfaces?
_____ Yes _____No
If the answer to this question is no, please sign below and include form in client file.
If the answer to this question is Yes, please complete the following (check each to verify performance):
 I have received DOE LSW training and have followed DOE LSW work practices and rules.
 I have performed DOE LSW Level 1 containment on the work site to prevent any dust or debris from
spreading beyond the work area to non-work areas.
 I certify under penalty of law that the above information is true and complete.
Certified Renovator Printed Name: __________________________________________________________
Certified Renovator Signature:_________________________________________Date:
Vol 1. July 17, 2013
/
/
Page 4
NEW JERSEY DEPARTMENT OF COMMUNITY AFFAIRS
DIVISION OF HOUSING AND COMMUNITY RESOURCE
WEATHERIZATION ASSISTANCE PROGRAM
Checklist for Performing RRP on dwelling built before 1978.
Client Name:_____________________________________________________ File ID:__________________
Address:_________________________________________________________Year Built:_______________
The following must be performed if weatherization work involves the disturbance of painted surfaces six
square feet or greater for interior or twenty square feet or greater for exterior or otherwise triggers EPA
RRP lead rules (check each to verify performance):



















Warning signs posted at entrance to work area.
Work area contained to prevent spread of dust and debris (containment areas).
All objects in the work area removed or covered (interiors).
HVAC ducts in the work area closed and covered (interiors).
Windows in the work area closed and covered (interiors).
Windows in and within 20 feet of the work area closed and covered (exteriors).
Doors in the work area closed and sealed (interiors).
Doors in and within 20 feet of the work area closed and sealed (exteriors).
Doors that must be used in the work area covered to allow passage but prevent spread of dust.
Floors in the work area covered with taped-down plastic (interiors).
Ground covered by plastic extending 10 feet from work area—plastic anchored to building and weighed
down by heavy objects (exteriors).
Vertical containment installed if property line prevents 10 feet of ground covering, or if necessary to
prevent migration of dust and debris to adjacent property (exteriors).
Waste contained on-site and while being transported off-site.
Work site properly cleaned after renovation.
All chips and debris picked up, protective sheeting misted, folded dirty side inward, and taped for
removal.
Work area surfaces and objects cleaned using HEPA vacuum and/or wet cloths or mops (interiors).
Performed post-renovation cleaning verification (describe results, including the number of wet and dry
cloths used):
.
If dust clearance testing was performed instead, attach a copy of report.
I certify under penalty of law that the above information is true and complete.
Certified Renovator Printed Name: __________________________________________________________
Certified Renovator Signature:_________________________________________Date:
Vol 1. July 17, 2013
/
/
Page 5
NEW JERSEY DEPARTMENT OF COMMUNITY AFFAIRS
DIVISION OF HOUSING AND COMMUNITY RESOURCE
WEATHERIZATION ASSISTANCE PROGRAM
Home Health & Safety Assessment / Notice of Observed Hazards
Client Name:________________________________________ File ID:___________________Date of Assessment:
Address:___________________________________________________________________________________Year
Housing Type: Single Family / Manufactured / Townhome / Low-Rise Multifamily / Four-Plus Story
/
/
Built:___________
Exterior Site/Building Inspection
Issue/Hazard
Description/Location/Severity
Estimated Costs
Structural
&
Roofing (Costs in
package SIR as
Incidental Repair)
Potential Asbestos
Siding - Surface &
Subsurface (Costs
included w/ ECM)
Moisture Intrusion/
Site
Drainage/
Gutters/Other
$___________
Pest
Intrusion
Prevention/
Removal
$___________
Suspected
Paint
Containing
Lead
(pre 1978)
Necessary Correction (Common Corrections Noted)
& Relationship to Wx Work
Minor corrections performed as incidental repair.
Cause for Deferral?
Referral Options
No / Yes
Remove/replace w/ ECM costs. Assure minimal No / Yes
breakage w/ proper containment & disposal. Inform
client that suspected asbestos siding is present and how
precautions will be taken for containment and to ensure
minimal breakage of siding.
Moderate/severe moisture conditions must be corrected No / Yes
or the unit deferred. Mold cleaning not allowed.
Only if preventing Wx or potential for damage to No / Yes
installed measures.
Intrusion prevention measures
allowed.
Use LSW & RRP if disturbing potential lead.
No / Yes
$___________
Vol 1. July 17, 2013
Page 6
NEW JERSEY DEPARTMENT OF COMMUNITY AFFAIRS
DIVISION OF HOUSING AND COMMUNITY RESOURCE
No / Yes
Other
$___________
Mechanical/Appliance Inspection
Issue/Hazard
Description/Location/Severity
Estimated Costs
Heating
(CO, Use LIHEAP protocols.
Moisture, Electrical,
Gas, Operation)
If DOE WAP:
$___________
Cooling (Moisture, Use LIHEAP protocols.
Electrical)
If DOE WAP:
$___________
Water Heater (CO, Use LIHEAP protocols.
Moisture, Electrical,
Gas, Operation)
If DOE WAP:
$___________
Ventilation (Attic, Complete ASHRAE Checklist &
Basement,
Local, Pre-Weatherization CFM:
Dryer,
Whole
Whole House:________________
House)
$___________
Kitchen:____________________
Necessary Correction (Common Corrections Noted)
Cause for Deferral?
& Relationship to Wx Work
Referral Options
Corrections w/ LIHEAP. If WAP, must attempt as ECM No / Yes
before H&S funds.
Corrections w/ LIHEAP only to facilitate heating or No / Yes
medical condition w/ Dr.’s note. If WAP, must attempt
as ECM before H&S funds.
Corrections w/ LIHEAP. If WAP, must attempt as ECM No / Yes
before H&S funds.
Proper venting required. Seal & vent exhaust ducts to No / Yes
outside w/ shortest run. Assure kitchen has operable 100
CFM tested fan, full baths a 50 CFM tested fan, or meet
ASHRAE 62.2 whole house calculation. Whole house
ontinuous exhaust system required in Tier 1 radon
municipalities and recommended in Tier 2. Defer when
high moisture/pollutants are present & cannot mitigate.
Bath:______Location:__________
Bath:______Location:__________
Vol 1. July 17, 2013
Page 7
NEW JERSEY DEPARTMENT OF COMMUNITY AFFAIRS
DIVISION OF HOUSING AND COMMUNITY RESOURCE
Other:_______________________
Space
Removal
Heater
Remove & dispose of unvented space heaters. ANSI No / Yes
A21.11.2 labeled secondary units okay. Electric heater
removal recommended.
$___________
Other
No / Yes
$___________
Basement/Crawlspace Inspection
Issue/Hazard
Description/Location/Severity
Estimated Costs
Structural (Costs in
package SIR as
Incidental Repair)
Return Ducts (if not
sealed as ECM)
Necessary Correction (Common Corrections Noted)
& Relationship to Wx Work
Minor corrections performed as incidental repairs.
Cause for Deferral?
Referral Options
No / Yes
Seal return ducts if CO, pollutants, or moisture present.
No / Yes
$___________
Electrical/Fire
Hazard (if not w/
ECM)
$___________
Potential
Friable
Asbestos (Removal
or Encapsulation)
Include w/ LIHEAP or ECM costs when a component of No / Yes
a measure. Correct with H&S if necessary to perform
Wx.
DO NOT DISTURB. Test & correction by AHERA No / Yes
professional only. Charged w/ LIHEAP if part of related
furnace work. Friable asbestos must be corrected or the
unit deferred.
$___________
Mold & Moisture
and
Biological
Conditions
Vol 1. July 17, 2013
Moderate/severe moisture & biological conditions must No / Yes
be corrected or the unit deferred. Mold cleaning not
allowed.
Page 8
NEW JERSEY DEPARTMENT OF COMMUNITY AFFAIRS
DIVISION OF HOUSING AND COMMUNITY RESOURCE
$___________
Exposed Dirt
Install sealed vapor barrier where site conditions permit. No / Yes
Optional for mobile homes.
$___________
Clutter/Access
Perform removal or correction necessary to allow access No / Yes
for effective Wx.
$___________
No / Yes
Other
$___________
Attic Inspection
Issue/Hazard
Description/Location/Severity
Estimated Costs
Structural (Costs in
package SIR as
incidental repair)
Necessary Correction (Common Corrections Noted)
& Relationship to Wx Work
Minor corrections performed as incidental repairs.
Cause for Deferral?
Referral Options
No / Yes
Potential Asbestos –
Vermiculite
(No
corrections allowed,
testing required)
Return Ducts (if not
sealed as ECM)
DO NOT DISTURB. Do not perform blower door tests No / Yes
or additional attic assessment once observed. Requires
AHERA testing before any work. If positive for asbestos
in Vermiculite the unit must be deferred.
Seal return ducts if CO, pollutants, or moisture present.
No / Yes
$___________
Electrical/Knob &
Tube/Fire Hazard
(if not w/ ECM)
Vol 1. July 17, 2013
Include w/ LIHEAP or ECM costs when a component of No / Yes
a measure. Correct with H&S if necessary to perform
Wx.
Page 9
NEW JERSEY DEPARTMENT OF COMMUNITY AFFAIRS
DIVISION OF HOUSING AND COMMUNITY RESOURCE
$___________
Mold & Moisture
and
Biological
Conditions
Moderate/severe moisture & biological conditions must No / Yes
be corrected or the unit deferred. Mold cleaning not
allowed.
$___________
Clutter/Access
Perform removal or correction necessary to allow access No / Yes
for effective Wx.
$___________
No / Yes
Other
$___________
Garage/Storage Inspection
Issue/Hazard
Description/Location/Severity
Estimated Costs
Garage
Air
Intrusion (if not
sealed as ECM)
Necessary Correction (Common Corrections Noted)
& Relationship to Wx Work
Seal all penetrations between garage and living space.
Cause for Deferral?
Referral Options
No / Yes
$___________
Return Ducts (if not
sealed as ECM)
Seal return ducts if CO, pollutants, or moisture present No / Yes
and not meeting SIR.
$___________
Vol 1. July 17, 2013
Page 10
NEW JERSEY DEPARTMENT OF COMMUNITY AFFAIRS
DIVISION OF HOUSING AND COMMUNITY RESOURCE
Electrical/Fire
Hazard (if not w/
ECM)
Include w/ LIHEAP or ECM costs when a component of No / Yes
a measure. Correct with H&S if necessary to perform
Wx.
$___________
Hazardous
Chemicals/VOCs
High concentrations of hazardous chemicals must be No / Yes
removed from the living space or the unit deferred.
$___________
Clutter/Access
Perform removal or correction necessary to allow access No / Yes
for effective Wx.
$___________
Other
No / Yes
$___________
Interior/Conditioned Space Inspection
Issue/Hazard
Description/Location/Severity
Estimated Costs
Structural (Costs in
package SIR as
incidental repair)
Necessary Correction (Common Corrections Noted)
Cause for Deferral?
& Relationship to Wx Work
Referral Options
Performed as incidental repairs and must fall within the No / Yes
package SIR or defer unit.
Electrical/Fire
Hazard (if not w/
ECM)
Include w/ LIHEAP or ECM costs when a component of No / Yes
a measure. Correct with H&S if necessary to perform
Wx.
Vol 1. July 17, 2013
Page 11
NEW JERSEY DEPARTMENT OF COMMUNITY AFFAIRS
DIVISION OF HOUSING AND COMMUNITY RESOURCE
$___________
Mold & Moisture
and Biological
Conditions
Moderate to severe moisture & biological creating No / Yes
conditions must be corrected or the unit deferred. Mold
cleaning not allowed.
$___________
Perform removal or correction necessary to allow access No / Yes
for effective Wx.
Clutter/Access
$___________
Paint
Lead
Use Lead Safe Work practices and follow RRP No / Yes
requirements where Wx will disturb suspected lead paint.
Smoke/CO Alarm
Installation or Fire
Extinguisher
Install alarms where not present, functioning, or within No / Yes
their useful life. Extinguisher for when Wx impacts solid
fuel heat.
Suspected
Containing
(pre 1978)
$___________
$___________
Other
No / Yes
$___________
Health & Safety Assessment/Testing
Assessments & Tests w/ Cost & Signature of Tester (include results Test Results
documentation w/ client file and provide copies to client)
$______ H&S Assessment (required)_______________________________
$______ Combustion Safety (conditional)____________________________
Vol 1. July 17, 2013
Cause for Deferral?
Referral Options
No / Yes
Page 12
NEW JERSEY DEPARTMENT OF COMMUNITY AFFAIRS
DIVISION OF HOUSING AND COMMUNITY RESOURCE
$______ ASHRAE 62.2 (conditional)_______________________________
$______ Radon (conditional)______________________________________
$______ Asbestos (conditional)____________________________________
$______ Lead (optional)__________________________________________
$______ Moisture (optional)______________________________________
$______ Voltage/Electrical (optional)_______________________________
$______ Other (explain)__________________________________________
Deferral Based On Unreasonable Health & Safety Costs
Total estimated DOE WAP cost of necessary & allowed
$
Health and Safety (Assessments, Testing, Corrections, Etc.)
Costs for correcting Health & Safety cannot exceed $1,300 without DCA
Program Supervisor Approval. Costs between $650 and $1,300 must be
approved by a State Program Monitor.
Program Operations (ECMs, Audit, Incidental, Etc.) $
Note: this does not include Health & Safety Costs
Percent
(Health & Safety costs divided by unit cost for %
Program Operations):
State Signature for Approval of H&S Costs at or above $650 (or include written approval) :
Not all health and safety conditions prevent weatherization (Wx) work. Only health and safety corrections necessary for Wx to proceed or to
prevent worsening existing conditions as a result of Wx activity can be addressed with WAP funds and must be within reasonable costs. The New
Jersey WAP is not responsible for correcting preexisting conditions in the home and deferral may be necessary; however, it is expected that the
local agency makes efforts to identify assistance where WAP funds cannot be used to correct health and safety conditions. Use the
www.wxplushealth.org “Find a Provider” tool to locate potential resources in your area.
I have been advised of the above observed health and safety conditions and understand that this assessment is preliminary and does not necessarily
reflect all of the health and safety concerns within my home, actual costs of correction, or the severity of the condition.
/
Client’s Printed Name
Client’s Signature
/
Date
Please contact your local WAP agency if you have any questions or concerns about the work being performed in your home.
(Include Auditor Contact, Address, Email, and Phone Number)
Vol 1. July 17, 2013
Page 13