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The Michigan DCH 0654 form plays a crucial role in the state's efforts to manage lead-based paint abatement activities. This form is essential for any firm planning to conduct lead abatement work in Michigan, as it ensures that the appropriate state department is notified at least three business days before the work begins. Compliance with the Michigan Lead Abatement Act of 1998 is mandatory, and submitting this form accurately is a key step in that process. The form collects vital information, including the project's start and end dates, contractor details, and the scope of work to be performed. It also requires the identification of certified professionals involved in the project, such as the lead abatement supervisor and risk assessor. Moreover, it provides options to specify the type of lead assessment being conducted and the occupancy status of the building. Incomplete submissions will not be approved, emphasizing the importance of thoroughness when filling out the form. Should there be any changes to the project schedule, a revision number must be indicated, and the updated information sent to the Healthy Homes Section promptly. Understanding the requirements and details of the DCH 0654 form is essential for compliance and the successful execution of lead abatement projects in Michigan.

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MAIL OR FAX TO:
MDCH - Healthy Homes Section
P.O. Box 30195
Lansing, MI 48909
Attn: Compliance Officer
FAX: 517-335-8800

Notification of Lead Abatement Activity

Any [firm] conducting lead-based paint [abatement] activities in the state of Michigan must notify the department of that activity not less than three (3) business days prior to its commencement, as required by §333.5472 of the Michigan Lead Abatement Act of 1998, as amended.

All information is required. Incomplete notifications will not be approved.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Notification Date:

 

 

Start Date:

 

 

End Date:

 

 

 

Revision #: (for

 

 

 

 

 

 

 

 

 

changes)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Reason for revision

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Scheduled work hours:_______________ to_______________

⃝

Weekends included

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Contractor Name:

 

 

 

 

 

 

 

 

 

MI Certification #:

C- ______________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Contact Person:

 

 

 

 

 

 

 

 

 

Phone #:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Certified Lead Abatement

 

 

 

 

 

 

 

 

MI Certification #:

 

 

 

Supervisor for this project:

 

 

 

 

 

 

 

 

P- ______________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Risk Assessor:

 

 

 

 

 

 

 

 

 

MI Certification #:

P- ______________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Type of lead-based paint assessment:

 

⃝ Risk assessment

 

⃝ Inspection

 

⃝ Assumed

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Building Owner:

 

 

 

 

 

 

Owner phone #:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Project/Site

 

 

 

 

 

 

City:

 

 

 

 

 

 

Zip:

 

Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Apartment numbers:

 

 

 

 

 

 

 

 

 

County:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Occupancy Status

 

 

Building Type

 

 

 

 

Occupancy Type

⃝ Occupied:

⃝ Vacant:

 

⃝ Single-family

 

 

 

 

⃝ Rental

(includes temporary

(abandoned/unoccupied)

 

⃝ Multi-family

 

 

 

 

⃝ Owner Occupied

relocation)

 

 

 

 

⃝ Child occupied facility

 

 

⃝ Vacant or unknown

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Housing Agency: (agency funding the project)

Contact Person:

Phone #:

Scope of Work

⃝ Interior ⃝ Exterior

⃝ Encapsulation ⃝ Enclosure ⃝ Component removal ⃝ Paint removal ⃝ Soil

Brief detail of scope of work (replace windows, exterior doors, interior doors, siding, encapsulate baseboards room #4, etc)

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1. Complete form.

2. Return to HHS at least three (3) business days prior to the commencement of abatement work.

3. If project schedule changes, mark the appropriate revision number at the top of the form and send in at least 24 hours prior to change.

DCH-0654 Revised (06/12)

➤ PDF File

Form Specifications

Fact Name Details
Form Purpose The Michigan DCH 0654 form is used to notify the Department of Community Health about lead abatement activities.
Notification Requirement Any firm conducting lead abatement must notify the department at least three business days before starting the work.
Governing Law This form is governed by §333.5472 of the Michigan Lead Abatement Act of 1998, as amended.
Incomplete Submissions Notifications that are incomplete will not be approved by the department.
Revision Process If there are changes to the project schedule, the appropriate revision number must be marked on the form.
Submission Methods The completed form can be mailed or faxed to the Healthy Homes Section of the MDCH.
Contact Information Firms must provide contact details, including a phone number for the contractor and the compliance officer.
Scope of Work The form requires a detailed description of the scope of work, including specific tasks and locations.
Occupancy Status Firms must indicate the occupancy status of the building, such as whether it is occupied or vacant.
Certification Numbers Contractors and supervisors must provide their Michigan certification numbers on the form.

Michigan Dch 0654: Usage Guidelines

Filling out the Michigan DCH 0654 form is an important step for notifying the state about lead abatement activities. Once the form is completed, it should be submitted to the Healthy Homes Section to ensure compliance with state regulations.

  1. Obtain the Michigan DCH 0654 form.
  2. Fill in the Notification Date, Start Date, and End Date of the abatement activity.
  3. If applicable, enter the Revision # for any changes.
  4. Indicate if Weekends are included in the scheduled work hours.
  5. Provide the Contractor Name and MI Certification #.
  6. Enter the Contact Person and their Phone #.
  7. Fill in the Certified Lead Abatement Supervisor and their MI Certification #.
  8. List the Risk Assessor and their MI Certification #.
  9. Select the type of lead-based paint assessment: Risk assessment, Inspection, or Assumed.
  10. Provide the Building Owner name and their Phone #.
  11. Fill in the Project/Site City, Zip, and Address.
  12. If applicable, enter Apt numbers and County.
  13. Indicate the Occupancy Status and Building Type.
  14. Select the Occupancy Type: Occupied, Vacant, Single-family, Rental, Multi-family, Owner Occupied, Child occupied facility, or Vacant or unknown.
  15. Provide the Housing Agency name and the Contact Person with their Phone #.
  16. Check the applicable Scope of Work: Interior, Exterior, Encapsulation, Enclosure, Component removal, Paint removal, or Soil.
  17. Write a brief detail of the scope of work, including specific tasks like "replace windows" or "encapsulate baseboards".
  18. Review the completed form for accuracy.
  19. Submit the form to the Healthy Homes Section at least three (3) business days before starting the abatement work.
  20. If there are any changes to the project schedule, mark the appropriate revision number at the top of the form and submit it at least 24 hours prior to the change.

Your Questions, Answered

What is the purpose of the Michigan DCH 0654 form?

The Michigan DCH 0654 form serves as a notification to the Michigan Department of Community Health (MDCH) regarding lead abatement activities. Any firm conducting lead-based paint abatement in Michigan must submit this form at least three business days before starting their work. This requirement is outlined in the Michigan Lead Abatement Act of 1998. The form ensures that the state is aware of ongoing lead abatement efforts, which helps in monitoring compliance and protecting public health.

Who needs to fill out the DCH 0654 form?

Any firm or contractor involved in lead-based paint abatement activities within Michigan is required to complete the DCH 0654 form. This includes contractors performing risk assessments, inspections, or actual abatement work. It is crucial that all relevant information is provided, as incomplete submissions will not be approved. This helps maintain safety standards and regulatory compliance during lead abatement projects.

What information is required on the form?

The DCH 0654 form requires various details, including the notification date, start and end dates of the abatement work, contractor information, and project specifics. You'll need to provide the names and certification numbers of the lead abatement supervisor and risk assessor, as well as details about the project site, occupancy status, and scope of work. The more complete and accurate the information, the smoother the approval process will be.

What happens if the project schedule changes?

If there are any changes to the project schedule, it is essential to indicate the revision number at the top of the form. You must submit this updated information at least 24 hours prior to the change. This ensures that the MDCH remains informed about the timing of lead abatement activities, which is critical for maintaining safety and compliance with state regulations.

How should I submit the DCH 0654 form?

The completed DCH 0654 form can be submitted either by mail or fax to the MDCH Healthy Homes Section. The mailing address is P.O. Box 30195, Lansing, MI 48909, Attention: Compliance Officer. If you prefer to fax the form, you can send it to 517-335-8800. Ensure that you send it at least three business days before the start of the abatement work to avoid any delays.

Common mistakes

  1. Failing to submit the form on time. The form must be sent to the Healthy Homes Section at least three business days before starting any lead abatement activity. Delays can lead to non-compliance.

  2. Leaving required fields blank. All sections of the form need to be completed. Incomplete submissions will not be approved, which can stall your project.

  3. Not including the correct contact information. Ensure that the contractor's name, phone number, and MI certification numbers are accurate. Incorrect information can lead to communication issues.

  4. Ignoring the revision process. If there are changes to the project schedule, you must indicate the revision number and submit the updated form at least 24 hours before the change.

  5. Not detailing the scope of work. Provide a clear description of the tasks involved, such as replacing windows or encapsulating baseboards. Vague descriptions can lead to misunderstandings.

  6. Overlooking occupancy status. Clearly state whether the building is occupied or vacant. This information is crucial for compliance and safety considerations.

Documents used along the form

The Michigan DCH 0654 form is an important document for notifying the state about lead abatement activities. When completing this form, you may also need to consider additional documents that support the lead abatement process. Here’s a list of related forms and documents that are often used alongside the DCH 0654.

  • Lead Abatement Contractor License: This document certifies that the contractor is licensed to perform lead abatement work in Michigan. It ensures that the contractor meets the state’s requirements for safety and compliance.
  • Risk Assessment Report: This report provides an evaluation of lead hazards in a property. It identifies areas where lead-based paint may pose a risk and outlines necessary remediation steps.
  • Lead-Based Paint Disclosure Form: Required by federal law, this form informs property buyers or renters about the presence of lead-based paint. It must be provided before the sale or lease of a property built before 1978.
  • Work Plan for Lead Abatement: This detailed document outlines the specific procedures and methods that will be used during the lead abatement process. It helps ensure that the work is carried out safely and effectively.
  • Post-Abatement Clearance Report: After the abatement work is completed, this report verifies that the area is safe for occupancy. It includes results from testing conducted to ensure lead levels are below acceptable limits.

Using these documents in conjunction with the Michigan DCH 0654 form can help ensure compliance with state and federal regulations. Proper documentation promotes safety and transparency in lead abatement activities.

Similar forms

The Michigan DCH 0654 form is essential for notifying the state about lead abatement activities. Several other documents serve similar purposes in various contexts. Here are seven documents that share similarities with the DCH 0654 form:

  • Lead-Based Paint Disclosure Form: This document is used by sellers and landlords to inform buyers or tenants about the presence of lead-based paint in properties. Like the DCH 0654, it ensures compliance with federal regulations regarding lead exposure.
  • Environmental Assessment Report: Conducted before construction or renovation, this report evaluates potential environmental hazards, including lead. It parallels the DCH 0654 in its focus on safety and compliance.
  • Renovation, Repair, and Painting (RRP) Notification Form: This form is required for contractors performing renovations in homes built before 1978. It notifies the EPA of lead-safe practices, similar to how the DCH 0654 notifies the state of abatement activities.
  • Asbestos Abatement Notification Form: Similar in purpose, this document informs authorities about asbestos removal activities. Both forms aim to protect public health by ensuring proper notification and compliance.
  • Hazardous Waste Notification Form: This form is used to notify environmental agencies about the handling of hazardous waste. It shares the same goal of ensuring safety and regulatory compliance as the DCH 0654.
  • Building Permit Application: Required for construction or renovation projects, this application ensures that all work meets local codes and regulations. Like the DCH 0654, it is a formal notification to authorities about planned activities.
  • Emergency Response Plan: This document outlines procedures for responding to hazardous situations, including lead exposure. It parallels the DCH 0654 in its focus on safety and preparedness in potentially hazardous environments.

Dos and Don'ts

When filling out the Michigan DCH 0654 form, it's essential to follow specific guidelines to ensure a smooth process. Here are seven things to do and not do:

  • Do complete all sections of the form thoroughly.
  • Do submit the form at least three business days before starting any lead abatement activities.
  • Do include accurate contact information for all parties involved.
  • Do indicate the type of lead-based paint assessment being conducted.
  • Don't leave any sections blank; incomplete forms will not be approved.
  • Don't forget to update the form if there are changes to the project schedule.
  • Don't submit the form without verifying that all information is correct.

By adhering to these guidelines, you can help ensure compliance with the Michigan Lead Abatement Act and facilitate a more efficient notification process.

Misconceptions

Understanding the Michigan DCH 0654 form is crucial for anyone involved in lead abatement activities. However, several misconceptions can lead to confusion. Here are six common misunderstandings:

  • Notification is optional. Some believe that notifying the Michigan Department of Community Health (MDCH) is not necessary. In reality, any firm conducting lead-based paint abatement must notify the department at least three business days before starting work.
  • Incomplete forms will be accepted. It is a common misconception that incomplete notifications might still be processed. However, the MDCH explicitly states that incomplete notifications will not be approved.
  • Only certain contractors need to file. Many think that only specific contractors must submit the DCH 0654 form. In fact, any firm conducting lead abatement activities in Michigan is required to notify the department.
  • Changes to the project schedule can be communicated later. Some individuals believe they can inform the MDCH about changes after they occur. The correct procedure requires notifying the department at least 24 hours in advance of any changes, marking the revision number on the form.
  • The form is only for interior projects. It is a misconception that the DCH 0654 form applies only to interior lead abatement. The form covers both interior and exterior projects, as well as various types of work such as encapsulation and soil remediation.
  • All types of lead assessments are treated the same. Some assume that all lead assessments require the same information on the form. However, the form allows for different types of lead-based paint assessments, such as risk assessments and inspections, which may have specific requirements.

By clarifying these misconceptions, firms can ensure they comply with Michigan's lead abatement regulations effectively.

Key takeaways

When filling out the Michigan DCH 0654 form, keep these key points in mind:

  • Notification Requirement: You must notify the department at least three business days before starting any lead abatement activities.
  • Complete Information: Ensure all sections of the form are filled out. Incomplete submissions will not be accepted.
  • Revision Process: If there are any changes to the project schedule, update the revision number and submit the form again at least 24 hours before the change.
  • Contact Information: Provide accurate contact details for all parties involved, including the contractor and the owner, to facilitate communication.

By following these guidelines, you can help ensure a smooth notification process for lead abatement activities in Michigan.