Homepage Blank Florida Dh 1777 PDF Form
Article Guide

The Florida DH 1777 form serves as a crucial tool in the state's efforts to monitor and manage radon levels in nonresidential buildings. This form is specifically designed for various facility types, including hospitals, schools, nursing homes, and correctional facilities, ensuring that each type of building is appropriately assessed. It requires detailed information about the facility and its owner, such as names, addresses, and contact details, to facilitate effective communication and follow-up. Additionally, the form includes sections dedicated to building characteristics, including its age, foundation type, and HVAC system, which are vital for understanding potential radon exposure risks. Measurement results are meticulously documented, specifying the type of radon measurement conducted, the dates of testing, and the qualifications of the personnel involved in the assessment. By capturing this comprehensive data, the DH 1777 form not only aids in compliance with state regulations but also plays a significant role in safeguarding public health by ensuring that radon levels are monitored and managed effectively across various nonresidential settings.

Document Preview

Bureau of Environmental Health

Radon Program

Mandatory Measurements

NONRESIDENTIAL RADON MEASUREMENT REPORT

FOR BUILDINGS OTHER THAN SINGLE OR MULTI FAMILY DWELLING

Page ___ of ___

SECTION 1: FACILITY AND OWNER INFORMATION

Facility Information:

Owner Information:

Facility Name (as licensed, registered, or listed with state)

Physical location (Street Address) of Facility Site

City

County

Zip

Name of Contact Person

Name of Owner

Street Address

City

State

Zip

()

Phone Number

()

TitlePhone Number

Facility type as licensed or registered (Submit individual facilities separate. I.E. A Day Care and School at the same place):

Assisted Living Facility (previously ACLF)

Hospitals (Acute Care, Physical Rehab., Psychiatric, or Intensive

Alcohol, Drug Abuse or Mental Health

Residential Treatment)

Correctional Facility or Jail

Nursing Home/Skilled Nursing Facility

Day Care Center (pre kindergarden)

Public School (K-12)

Delinquency Program (Ex: Start Center, Training School)

Private School (K-12)

OTHER (specify)

 

 

 

 

 

 

 

 

 

 

SECTION 2: BUILDING INFORMATION

Building Name or ID Number (If Applicable)Street Address of Building (If Different From Facility Site)

Buildings per address ___; Building No. ___ of ___ requiring testing.

Number of measurements required in this building during this testing period: ______ initial or 5 year retest, ______ follow-up

Cumulative number of measurements reported for this testing period: ______ initial or 5 year retest, ______ follow-up

____ No. of Stories, ____ No. of Stories Occupied, ________ Age of Building in Years (or year built)

Foundation/Floor

System:

Slab

Crawlspace

Pier

Floored Basement

Bare Earth Basement

Other(specify)

 

CHECK ALL THAT APPLY

 

HVAC System:

 

 

HVAC:

Non-ventilating HAC:

Other HVAC:

(system with fresh air intake)

(system without fresh air intake)

Window/Wall Unit

Single Zone / single

Central Ducted A/C

No A/C

return

Central Ducted

No Heat

Multiple Zones /

Heat

Other (specify)

multiple returns

Space Heater

 

 

 

 

 

For Official Use Only:

 

Date

Reviewed

Entered

 

 

Received

By

By

 

 

 

 

 

 

DH 1777, Edition 7/15 (Replaces Jan 93 Edition)

 

 

 

 

 

 

 

SECTION 3: RESULTS

 

 

 

 

Measurement Type: Initial or 5 Year Retest, Follow-up

 

 

 

 

Dates of Measurement: FROM

/ /

 

TO

/ /

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Person who performed Measurement (Placed Device)

 

 

 

Certificate No. (If Applicable)

 

 

 

 

 

 

 

 

 

 

 

 

 

Story

 

Room

Result

 

Units

 

Device

 

 

Time in Hours

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

P for pCi/L or W for WL

AC-Activated Carbon Adsorption, AT-Alpha Track, CR-Continuous Radon Monitor, CW-Continuous Working Level Monitor, EL-Electret Ion Chamber Long Term, ES-Electret Ion Chamber Short Term, LS- Liquid Scintillation, RP-RPISU, UT-Unfiltered Alpha Track

SECTION 4

COMPLETE ONLY IF MEASUREMENTS ARE PERFORMED BY A RADON MEASUREMENT BUSINESS

Name of Business and Cert. No.

Name of Specialist and Cert. No.

Signature of Specialist

SECTION 5

COMPLETE ONLY IF MEASUREMENTS ARE PERFORMED BY STAFF EMPLOYED BY THE FACILITY

I hereby certify that the Radon measurements reported herein have been performed in accordance with Chapter 64E-5, Florida Administrative Code, and Chapter 404, Florida Statutes.

Authorized Representative of Facility

 

Date

Upon completion of this form, send to:

Department of Health

Bureau of Environmental Health / Radon Program

4052 Bald Cypress Way, Bin #A12

Tallahassee, FL 32399-1720

You may scan the report and email it to [email protected]

For Assistance in Completing this Form call 1-800-543-8279

Form Specifications

Fact Name Fact Details
Form Purpose The Florida DH 1777 form is used to report nonresidential radon measurements for buildings other than single or multi-family dwellings.
Governing Laws This form is governed by Chapter 64E-5 of the Florida Administrative Code and Chapter 404 of the Florida Statutes.
Required Information The form requires detailed information about the facility, including the facility name, address, owner information, and contact details.
Measurement Reporting Results must include the type of measurement, dates, and the name of the person who performed the measurement, ensuring accountability.
Submission Process Upon completion, the form must be submitted to the Department of Health, either by mail or via email to [email protected].

Florida Dh 1777: Usage Guidelines

Filling out the Florida DH 1777 form is an important step in ensuring compliance with radon measurement regulations. Once completed, this form should be submitted to the appropriate department for processing. Below are the steps to guide you through the completion of the form.

  1. Facility Information: Enter the facility name as it is licensed, registered, or listed with the state.
  2. Physical Location: Provide the street address, city, county, and zip code of the facility.
  3. Contact Information: Fill in the name of the contact person, their title, and phone number.
  4. Owner Information: Include the owner's name, street address, city, state, and zip code.
  5. Facility Type: Check the box that corresponds to the type of facility (e.g., Assisted Living Facility, Hospital, etc.).
  6. Building Information: If applicable, provide the building name or ID number and the street address of the building if it differs from the facility site.
  7. Building Details: Indicate the number of buildings per address and the specific building number requiring testing.
  8. Measurements Required: State the number of measurements required during this testing period and the cumulative number of measurements reported.
  9. Building Characteristics: Fill in the number of stories, number of occupied stories, and the age of the building.
  10. Foundation/Floor System: Check all applicable options regarding the foundation or floor system.
  11. HVAC System: Indicate the type of HVAC system and check all applicable options.
  12. Measurement Results: Specify the measurement type (Initial or 5 Year Retest, Follow-up) and provide the dates of measurement.
  13. Measurement Personnel: Enter the name and certificate number of the person who performed the measurement.
  14. Measurement Details: Record the story, room, result units, and time in hours for the measurement.
  15. Radon Measurement Business: If applicable, complete the section with the business name, specialist name, and their certificate numbers.
  16. Certification: If measurements were performed by facility staff, the authorized representative must certify the results and provide the date.
  17. Submission: Send the completed form to the Department of Health, Bureau of Environmental Health, or email it to the provided address.

Your Questions, Answered

What is the purpose of the Florida DH 1777 form?

The Florida DH 1777 form is designed for nonresidential radon measurement reporting. It is used to document radon levels in various types of facilities, such as hospitals, schools, and assisted living facilities. By measuring radon levels, the form helps ensure that these buildings maintain safe indoor air quality, protecting the health of occupants and staff.

Who is required to complete the DH 1777 form?

What information is needed to fill out the DH 1777 form?

To complete the DH 1777 form, you will need to provide detailed information about the facility and the building where measurements are taken. This includes the facility name, physical address, contact person, and owner details. Additionally, you must specify the type of facility, the building's age, foundation type, HVAC system details, and the results of the radon measurements. Accurate data is crucial for effective reporting and compliance.

How should the completed DH 1777 form be submitted?

Once the DH 1777 form is completed, it should be submitted to the Florida Department of Health's Bureau of Environmental Health. You can send the form by mail to the address provided on the form or scan it and email it to [email protected]. For any questions or assistance with the form, you can call the designated helpline at 1-800-543-8279.

Common mistakes

  1. Incomplete Facility Information: Failing to provide all required details about the facility, such as the facility name, physical address, and owner information, can lead to delays or rejections of the form.

  2. Incorrect Facility Type Selection: Selecting the wrong facility type can result in improper categorization. Ensure that the facility type accurately reflects the nature of the establishment.

  3. Missing Measurement Details: Not specifying the number of measurements required or the cumulative number reported can create confusion. Always include these details for clarity.

  4. Omitting HVAC System Information: Failing to check all applicable HVAC system options can lead to an incomplete assessment. This information is crucial for understanding the building's air circulation.

  5. Errors in Measurement Dates: Providing incorrect dates for the measurement period can invalidate the results. Double-check the dates to ensure accuracy.

  6. Neglecting Signatures: Not obtaining the necessary signatures from the authorized representative or the measurement specialist can result in the form being considered incomplete. Ensure all required signatures are present before submission.

Documents used along the form

The Florida DH 1777 form is essential for documenting radon measurements in nonresidential buildings. However, several other forms and documents often accompany this report to ensure compliance with health and safety regulations. Below is a list of these documents, each serving a specific purpose in the radon measurement and reporting process.

  • Florida DH 1778 Form: This form is used for reporting radon measurement results specifically for residential properties. It helps homeowners understand their radon levels and necessary actions.
  • Radon Measurement Business Certification: This document certifies that a business is qualified to conduct radon measurements. It ensures that the testing is performed by trained professionals.
  • Radon Mitigation System Installation Report: After radon levels are found to be high, this report documents the installation of mitigation systems designed to reduce radon concentrations in buildings.
  • Radon Testing Device Calibration Certificate: This certificate confirms that the radon testing devices used are calibrated and functioning correctly, ensuring accurate measurement results.
  • Environmental Health Inspection Report: This report may be generated during inspections of facilities to assess compliance with health standards, including radon safety measures.
  • Facility Owner Acknowledgment Form: This form indicates that the facility owner has been informed about the radon measurement results and understands the implications for health and safety.
  • Follow-up Measurement Report: If initial testing shows elevated radon levels, this report documents follow-up measurements taken to verify the effectiveness of mitigation efforts.
  • Radon Awareness Information Brochure: This educational material provides information on radon, its health risks, and steps to take if high levels are detected, helping to raise awareness among facility occupants.

These documents work together to create a comprehensive approach to radon measurement and mitigation. Understanding each form's role can help ensure that facilities maintain a safe environment for occupants and comply with state regulations.

Similar forms

The Florida DH 1777 form is a nonresidential radon measurement report. It shares similarities with several other legal documents related to health and safety regulations. Below are six documents that are comparable to the DH 1777 form, along with their specific similarities:

  • Florida DH 1766: This form is used for residential radon measurement. Like the DH 1777, it collects facility information, measurement results, and requires certification from a qualified individual.
  • EPA Radon Measurement Protocols: These guidelines outline procedures for measuring radon levels in various types of buildings. Both documents emphasize the importance of accurate measurements and compliance with safety standards.
  • Radon Mitigation System Installation Form: This document is used to report the installation of radon mitigation systems. Similar to the DH 1777, it requires detailed information about the facility and the methods used to ensure safety.
  • Florida DH 1778: This form is a follow-up report for radon testing. It shares the same structure as the DH 1777, focusing on measurement results and facility details, ensuring consistency in reporting.
  • Indoor Air Quality Assessment Report: This report evaluates air quality in buildings, including radon levels. Both documents require data collection and reporting to ensure public safety and compliance with health regulations.
  • Occupational Safety and Health Administration (OSHA) Compliance Form: This form is used for reporting workplace safety conditions. Like the DH 1777, it aims to protect individuals by ensuring that safety standards are met and documented properly.

Dos and Don'ts

When filling out the Florida DH 1777 form, attention to detail is crucial. Here are some important do's and don'ts to keep in mind:

  • Do ensure all facility and owner information is accurate and complete.
  • Do use the correct facility type as licensed or registered.
  • Do provide the correct number of measurements required during the testing period.
  • Do specify the foundation or floor system accurately.
  • Don't leave any sections blank unless instructed to do so.
  • Don't forget to include the name and certification number of the person who performed the measurements.

Following these guidelines can help ensure that your form is processed smoothly. It’s always a good idea to double-check your entries before submission. If you have any questions, consider reaching out for assistance.

Misconceptions

Understanding the Florida DH 1777 form is crucial for those involved in nonresidential radon measurement. However, several misconceptions can lead to confusion. Here are five common misunderstandings:

  • It is only for residential buildings. Many believe the DH 1777 form applies solely to homes. In reality, it is designed specifically for nonresidential buildings, such as schools, hospitals, and day care centers.
  • All radon measurements are the same. Some people think that any radon measurement can be reported using this form. However, the DH 1777 form requires specific types of measurements and documentation that vary based on the building's use and characteristics.
  • Only certified professionals can fill out the form. While it is true that measurements must be conducted by certified personnel, the form can be completed by an authorized representative of the facility as long as it accurately reflects the measurements taken.
  • There is no deadline for submission. Some may assume that the form can be submitted at any time. In fact, timely submission is essential for compliance with state regulations, and there may be specific deadlines based on the testing period.
  • The results are not important unless they are high. A common belief is that only high radon levels require attention. However, all results are important for assessing the safety of the environment and ensuring proper measures are taken, regardless of the outcome.

Being informed about these misconceptions can help ensure compliance and enhance safety in nonresidential buildings. Understanding the requirements and processes associated with the DH 1777 form is essential for all stakeholders involved.

Key takeaways

The Florida DH 1777 form is essential for documenting radon measurements in nonresidential buildings. Here are key takeaways to consider when filling out and using this form:

  • Accurate Facility Information: Ensure that the facility name and physical address are correctly filled out as registered with the state.
  • Owner Details: Include complete contact information for the facility owner, including name, address, and phone number.
  • Building Information: Specify the building name or ID, the number of stories, and the age of the building to provide context for the radon measurements.
  • Measurement Requirements: Clearly indicate the number of measurements required and whether they are initial, follow-up, or part of a five-year retest.
  • Measurement Results: Document the dates of measurement and the results, including the type of device used and the units of measurement.
  • Certification: If measurements are conducted by a radon measurement business, include the specialist's name and certification number for verification.
  • Submission Process: After completing the form, submit it to the Department of Health either by mail or email. Ensure it is sent to the correct address to avoid delays.

Completing the Florida DH 1777 form accurately is crucial for compliance with state regulations regarding radon testing in nonresidential buildings.