NEW JERSEY DEPARTMENT OF COMMUNITY AFFAIRS DIVISION OF HOUSING AND COMMUNITY
RESOURCES
New Jersey Weatherization Assistance Program
Home Health & Safety Assessment / Notice of Observed Hazards
Client Name:________________________________________ File ID:___________________Date of Assessment:
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/
Address:___________________________________________________________________________________Year Built:___________
Housing Type: Single Family / Manufactured / Townhome / Low-Rise Multifamily / Four-Plus Story
Exterior Site/Building Inspection
Issue/Hazard
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)
$___________
Other
Description/Location/Severity
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
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
or the unit deferred. Mold cleaning not allowed.
No / Yes
Only if preventing Wx or potential for damage to
installed measures. Intrusion prevention measures
allowed.
No / Yes
Use LSW & RRP if disturbing potential lead.
No / Yes
No / Yes
No / Yes
$___________
Vol 1. October 2, 2013
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NEW JERSEY DEPARTMENT OF COMMUNITY AFFAIRS DIVISION OF HOUSING AND COMMUNITY
RESOURCES
Mechanical/Appliance Inspection
Issue/Hazard
Estimated Costs
Heating (CO,
Moisture, Electrical,
Gas, Operation)
Necessary Correction (Common Corrections Noted)
& Relationship to Wx Work
Corrections w/ LIHEAP. If WAP, must attempt as ECM
before H&S funds.
Cause for Deferral?
Referral Options
No / Yes
Use LIHEAP protocols.
Corrections w/ LIHEAP only to facilitate heating or
medical condition w/ Dr.’s note. If WAP, must attempt
as ECM before H&S funds.
No / Yes
If DOE WAP:
$___________
Water Heater (CO,
Moisture, Electrical,
Gas, Operation)
Use LIHEAP protocols.
Corrections w/ LIHEAP. If WAP, must attempt as ECM
before H&S funds.
No / Yes
If DOE WAP:
$___________
Ventilation (Attic,
Basement, Local,
Dryer, Whole
House)
Complete ASHRAE Checklist &
Pre-Weatherization CFM:
No / Yes
$___________
Kitchen:____________________
Proper venting required. Seal & vent exhaust ducts to
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.
Remove & dispose of unvented space heaters. ANSI
A21.11.2 labeled secondary units okay. Electric heater
removal recommended.
No / Yes
If DOE WAP:
$___________
Cooling (Moisture,
Electrical)
Description/Location/Severity
Use LIHEAP protocols.
Whole House:________________
Bath:______Location:__________
Bath:______Location:__________
Other:_______________________
Space Heater
Removal
$___________
Other
Vol 1. October 2, 2013
No / Yes
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NEW JERSEY DEPARTMENT OF COMMUNITY AFFAIRS DIVISION OF HOUSING AND COMMUNITY
RESOURCES
$___________
Basement/Crawlspace Inspection
Issue/Hazard
Estimated Costs
Structural (Costs in
package SIR as
Incidental Repair)
Return Ducts (if not
sealed as ECM)
Description/Location/Severity
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
Include w/ LIHEAP or ECM costs when a component of
a measure. Correct with H&S if necessary to perform
Wx.
No / Yes
DO NOT DISTURB. Test & correction by AHERA
professional only. Charged w/ LIHEAP if part of related
furnace work. Friable asbestos must be corrected or the
unit deferred.
No / Yes
Moderate/severe moisture & biological conditions must
be corrected or the unit deferred. Mold cleaning not
allowed.
No / Yes
Install sealed vapor barrier where site conditions permit.
Optional for mobile homes.
No / Yes
Perform removal or correction necessary to allow access
for effective Wx.
No / Yes
$___________
Electrical/Fire
Hazard (if not w/
ECM)
$___________
Potential Friable
Asbestos (Removal
or Encapsulation)
$___________
Mold & Moisture
and Biological
Conditions
$___________
Exposed Dirt
$___________
Clutter/Access
$___________
Vol 1. October 2, 2013
Page 3
NEW JERSEY DEPARTMENT OF COMMUNITY AFFAIRS DIVISION OF HOUSING AND COMMUNITY
RESOURCES
No / Yes
Other
$___________
Attic Inspection
Issue/Hazard
Estimated Costs
Structural (Costs in
package SIR as
incidental repair)
Potential Asbestos –
Vermiculite (No
corrections allowed,
testing required)
Return Ducts (if not
sealed as ECM)
Description/Location/Severity
Necessary Correction (Common Corrections Noted)
& Relationship to Wx Work
Minor corrections performed as incidental repairs.
Cause for Deferral?
Referral Options
No / Yes
DO NOT DISTURB. Do not perform blower door tests
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
Include w/ LIHEAP or ECM costs when a component of
a measure. Correct with H&S if necessary to perform
Wx.
No / Yes
Moderate/severe moisture & biological conditions must
be corrected or the unit deferred. Mold cleaning not
allowed.
No / Yes
Perform removal or correction necessary to allow access
for effective Wx.
No / Yes
No / Yes
$___________
Electrical/Knob &
Tube/Fire Hazard
(if not w/ ECM)
$___________
Mold & Moisture
and Biological
Conditions
$___________
Clutter/Access
$___________
Vol 1. October 2, 2013
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NEW JERSEY DEPARTMENT OF COMMUNITY AFFAIRS DIVISION OF HOUSING AND COMMUNITY
RESOURCES
No / Yes
Other
$___________
Garage/Storage Inspection
Issue/Hazard
Estimated Costs
Garage Air
Intrusion (if not
sealed as ECM)
Description/Location/Severity
Necessary Correction (Common Corrections Noted)
& Relationship to Wx Work
Seal all penetrations between garage and living space.
Cause for Deferral?
Referral Options
No / Yes
Seal return ducts if CO, pollutants, or moisture present
and not meeting SIR.
No / Yes
Include w/ LIHEAP or ECM costs when a component of
a measure. Correct with H&S if necessary to perform
Wx.
No / Yes
High concentrations of hazardous chemicals must be
removed from the living space or the unit deferred.
No / Yes
Perform removal or correction necessary to allow access
for effective Wx.
No / Yes
$___________
Return Ducts (if not
sealed as ECM)
$___________
Electrical/Fire
Hazard (if not w/
ECM)
$___________
Hazardous
Chemicals/VOCs
$___________
Clutter/Access
Vol 1. October 2, 2013
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NEW JERSEY DEPARTMENT OF COMMUNITY AFFAIRS DIVISION OF HOUSING AND COMMUNITY
RESOURCES
$___________
No / Yes
Other
$___________
Interior/Conditioned Space Inspection
Issue/Hazard
Estimated Costs
Structural (Costs in
package SIR as
incidental repair)
Electrical/Fire
Hazard (if not w/
ECM)
Description/Location/Severity
Necessary Correction (Common Corrections Noted)
& Relationship to Wx Work
Performed as incidental repairs and must fall within the
package SIR or defer unit.
Cause for Deferral?
Referral Options
No / Yes
Include w/ LIHEAP or ECM costs when a component of
a measure. Correct with H&S if necessary to perform
Wx.
No / Yes
Moderate to severe moisture & biological creating
conditions must be corrected or the unit deferred. Mold
cleaning not allowed.
No / Yes
Perform removal or correction necessary to allow access
for effective Wx.
No / Yes
Use Lead Safe Work practices and follow RRP
requirements where Wx will disturb suspected lead paint.
No / Yes
$___________
Mold & Moisture
and Biological
Conditions
$___________
Clutter/Access
$___________
Suspected Paint
Containing Lead
(pre 1978)
Vol 1. October 2, 2013
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NEW JERSEY DEPARTMENT OF COMMUNITY AFFAIRS DIVISION OF HOUSING AND COMMUNITY
RESOURCES
$___________
Smoke/CO Alarm
Installation or Fire
Extinguisher
Install alarms where not present, functioning, or within
their useful life. Extinguisher for when Wx impacts solid
fuel heat.
No / Yes
$___________
No / Yes
Other
$___________
Health & Safety Assessment/Testing
Assessments & Tests w/ Cost & Signature of Tester (include results
documentation w/ client file and provide copies to client)
Test Results
$______ H&S Assessment (required)_______________________________
$______ Combustion Safety (conditional)____________________________
$______ ASHRAE 62.2 (conditional)_______________________________
$______ Radon (conditional)______________________________________
$______ Asbestos (conditional)____________________________________
$______ Lead (optional)__________________________________________
$______ Moisture (optional)______________________________________
$______ Voltage/Electrical (optional)_______________________________
$______ Other (explain)__________________________________________
Cause for Deferral?
Referral Options
No / Yes
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) :
Vol 1. October 2, 2013
Page 7
NEW JERSEY DEPARTMENT OF COMMUNITY AFFAIRS DIVISION OF HOUSING AND COMMUNITY
RESOURCES
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.
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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. October 2, 2013
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