HUD 96013 Needs/Extent of the Problem

Healthy Homes and U.S. Department of Housing OMB Approval No. 2539-0015

Lead Hazard Programs and Urban Development (expires mm/dd/201y)

Office of Healthy Homes and Lead Hazard Control

		Factor 2 – Need/Extent of the Problem			Page ___ of ___
		A. Provide information on Blood Lead Level (BLL) in children under 6 years of age in the most recent 12 month period for which data is available. If lead hazard control work will be done in multiple jurisdictions, provide total data for all jurisdictions. Complete either block A.1 or A.2, but not both. (If you complete both, HUD will use A.1) B. Location(s) where lead hazard control work will be done. See Instructions below.
		Name of Applicant
	A.1. Documented Blood Lead Level (BLL) in Jurisdiction				A.2. Documented Blood Lead Level (BLL) in Target Area
Blood Lead Level				Number of Children Under 6 Years		Blood Lead Level		Number of Children Under 6 Years
< 10 µg/dL						< 10 µg/dL
≥ 10 µg/dL						≥ 10 µg/dL
Total # Tested						Total # Tested
Total # Children < 6						Total # Children < 6
		A.3. Data sources on BLLs and children (e.g., list specific Health Department reports, relevant web pages, etc.)
		B. Where lead hazard control work will be done:
		1. State	2. County		3. Local jurisdiction (city/town/municipality)		4. Work area identification number		5. Exclude from work area?
		Instructions for block B, Where lead hazard control work will be done: 1. Identify each state/county/local jurisdiction (city/town/municipality) where lead hazard control work will be done. 2. Go to the OHHLHC home page, www.hud.gov/lead/. 3. In the home page’s discussion of the NOFA, click on the link for “Factor 2 - Need/Extent of the Problem.” 4. In the table of jurisdictions, indicate where the lead hazard control work will be done: a. Select the state. If the applicant is a State, go to step 5. b. Select the county. If the applicant is a county, go to step 5. c. Select the local jurisdiction (city/town/municipality). 5. Use the website to find the work area identification number. 6. In block B of this form, enter the two-letter State abbreviation, and the name of the county and the local jurisdiction, into columns B1, B2 and B3, as applicable. Then enter the work area identification number in column B4. 7. If a local jurisdiction within a larger jurisdiction will be excluded from the work area (e.g., a particular city within a county), find the excluded area’s identification number by using steps 4­ through 6, enter the identification number in column B4, and enter “Exclude” or another indicator that the jurisdiction will be exluded from the work area in column B5. 8. If there is more than one work area, repeat steps 4 through 7 for each additional work area. If there are more work areas than fit on this form, use additional forms, and fill in the page number at the top right of each form.
		Public reporting burden for this collection of information is estimated to average 1 hour. This includes the time for collecting, reviewing, and reporting the data. This information collection is collected during the application process and is used to select grantees under a competitive selection process. Section 1011 of Title X of the Housing and Community Development Act of 1992 authorizes this collection. Response to this request for information is required in order to receive the benefits to be derived. This agency may not collect this information, and you are not required to complete this form unless it displays a currently valid OMB control number.

form HUD-96013

(m/200y)