0923-0048 Form 110

Appendix I2.

Form Approved

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

FORM 110

ATSDR estimates the average public reporting burden for this collection of information as 10 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).

Interior Environmental Paint Assessment

___________________________			___________________________
Place ID Sticker Here			Inspector and Date
New Form for Each Room Draw Diagram on Reverse Side of Sheet (Indicate North)
INTERIOR XRF Instrument No: ________________________
Room No. __________ Total No. Doors __________ Total No. Windows __________
Test Component	Condition (I or D)	Deterioration (Percent)		XRF Result (mg/cm2)	Comments
Window Sash
Windowsill
Door
Door Jamb
Floor
Wall
Baseboard
Radiator
Cabinets/Shelves
Other

Condition

• Intact (I): no obvious visible deterioration

Fair (D): peeling, chipping, blistering, flaking, worn, chalking, alligatoring, cracking, or otherwise becoming separated from the substrate.