This publication offers a comprehensive collection of 70 "building blocks," which are primary prevention strategies that merit consideration by state and local governments and others in position to reduce exposure to hazards in housing and thereby help meet the Healthy People 2010 goal of eliminating childhood lead poisoning. Exemplary strategies span a broad spectrum which includes targeting high-risk properties; widely instituting safe work practices; building community capacity to check for hazards and work safety; delivering hazard assessment, control and prevention services; motivating action; screening high-risk housing; expanding financial resources; strengthening enforcement; raising public awareness and support; and establishing valuable partnerships. A strategy has been considered for inclusion as a building block if it is sensitive to the economics of affordable housing, consistent with the principles of public health, holds the potential for broad-scale impact, stands a reasonable possibility of implementation, and offers promise for reducing lead and other environmental health hazards in high-risk housing. The summary of each building block is coupled with an illustration of how the strategy has been implemented and contact information for at least one individual who is knowledgeable about this activity. The purpose of disseminating Building Blocks for Primary Prevention: Protecting Children from Lead-Based Paint Hazards is to allow programs and policymakers easy access to information about innovative and promising strategies that span the spectrum of primary prevention, from which they may select one or several to pursue based on their jurisdiction's needs and political and economic realities.# INTRODUCTION

# Context and Background
Exposure to lead continues to poison young children in the United States. Estimates based on data from 1999 and 2000 indicate that about 2.2% of children aged 1-5 years (about 434,000 children) have blood lead level (BLL) elevations at or above 10 micrograms per deciliter (10 g/dL). Healthy People 2010 (Objective 8-11) i calls for the eradication of lead poisoning as a public health problem by the year 2010 through the elimination of elevated blood lead levels in children.
Over the past decade, research has greatly expanded understanding of the sources and pathways of lead exposure in the residential environment and the effectiveness of a range of strategies to make housing safe. While children can be exposed to lead from a variety of other sources and pathways, the most significant cause of exposure is the presence of lead-based paint hazards in their homes, such as lead in non-intact paint, interior settled dust, exterior soil and dust, and hazards created by improperly conducted renovation work. Focus on the presence of lead-based paint and its lead content has given way to recognition of the importance of the condition of painted surfaces in older homes and the dangers of lead-contaminated dust. Chronic ingestion of settled lead dust on floors, windowsills, and other surfaces is now recognized as the foremost pathway of young children's exposure to lead in the home environment, and dust lead levels are recognized as the strongest predictor of risk.
Based on the recommendations of an interagency working group tasked with planning to achieve the 2010 lead elimination goal, the Federal Strategy for Eliminating Childhood Lead Poisoning ii emphasizes the essential need to require action before children are poisoned-by making the US housing stock lead-safe. The latest national survey of lead hazards in US housing makes clear the magnitude and complexity of this challenge: more than one-quarter of all US housing units pose "significant lead hazards." iii Yet the impact of most lead poisoning prevention programs is limited to the fraction of properties that are occupied by a child with an elevated blood lead level (less than two percent of hazardous units nationwide). While the need continues to improve blood lead screening and case management services, achieving the national 2010 goal of eliminating lead poisoning as a public health problem requires significantly increasing the impact of primary prevention strategies to make high-risk housing lead-safe.
The Centers for Disease Control and Prevention (CDC) has a longstanding responsibility and commitment to protecting children from lead poisoning. Since the early 1970s, CDC has made grants to help state and local health department lead poisoning prevention programs screen children at risk for lead poisoning or elevated blood lead levels (EBL), perform environmental investigations to determine the source children's exposure, and provide follow-up case management and educational services. At the national level, CDC works closely with other federal agencies committed to lead poisoning prevention, notably the US Department of Housing and Urban Development's Office of Healthy Homes and Lead Hazard Control (HUD OHHLHC), the US Environmental Protection Agency (EPA), and, within the US Department of Health and Human Services, the Centers for Medicare and Medicaid Services (CMS) and the Office of Community Services (OCS).
The Lead Poisoning Prevention Branch of CDC is fulfilling its commitment to the 2010 lead elimination goal through its grant program's requirement that jurisdictions develop and implement a strategic plan for elimination that includes primary prevention, partnering, and program evaluation. Through this Building Blocks publication, the Branch now offers grantees and others access to a compendium of promising primary prevention approaches to reduce exposure to lead paint hazards.

# Building Blocks for Primary Prevention: Protecting Children from Lead-Based Paint Hazards
State and local childhood lead poisoning prevention programs (CLPPPs) universally acknowledge the importance of primary prevention and are beginning to address it in their strategic plans and funding applications. However, many programs' primary prevention efforts are confined to parent education about hygiene, nutrition, and housekeeping, despite research that makes clear the limitations of these interventions for families whose homes pose significant lead hazards. Inability to institute durable primary prevention is caused in part by the pressure to focus resources and attention on secondary prevention by identifying and managing individual cases of elevated childhood blood lead level (BLL). Indeed, in communities where follow-up on actual poisonings is limited to educating family members about lead hazards and behavioral change (because public resources are not available to control identified lead hazards and halt further exposure), meaningful primary prevention can seem like an extremely remote target. Programs facing these circumstances need ideas for sharing responsibility within the jurisdiction to stop repeat offenders, expand access to lead-safe housing, and ultimately arrest the cycle of inferior housing that continually produces new poisonings.
While no city or state with a significant stock of leaded housing has successfully assembled all of the elements needed to make primary prevention a reality across the jurisdiction, state and local lead poisoning prevention programs across the country and their partners in other agencies and the private sector have implemented a multitude of innovative and successful primary prevention strategies over past years. Workshops and conferences periodically feature model programs, but the prospect of replicating an entire program with multiple components and elements can be daunting to the CLPPP seeking to evolve beyond screening and case management. Difficulty in achieving program transformation to primary prevention is only compounded within an overwhelmed public agency that is surrounded by a change-resistant or risk-averse political environment. Since most successful primary prevention programs consist of multiple elements, specific strategies can be considered individually or in combination.
The multitude of innovative strategies to identify, control, and prevent lead hazards in housing before a child is poisoned that are currently being implemented across the country has never been systematically documented or described in a way that makes information about their design and implementation readily accessible. Programs and their jurisdictions need this information at the "building block" level in order to decide which strategies to pursue based on local needs and conditions. This document identifies and describes individual building blocks across the spectrum of primary prevention strategies in order to create access to knowledge about tangible and realistic opportunities for progress and program evolution in identifying, controlling, and preventing lead poisoning and other housing-related health hazards.

# Scope and Limitations
The research for Building Blocks for Primary Prevention: Protecting Children from Lead-Based Paint Hazards was guided by the descriptions of primary prevention in CDC's 1997 screening guidelines and 2002 case management guidelines, which emphasize eliminating and controlling toxic exposures at the source. While primary prevention necessarily encompasses activities that address all sources of exposure to lead, this publication is focused on strategies for preventing and controlling lead hazards in housing, the foremost cause of poisoning.

# Building Blocks for Primary Prevention: Protecting Children from Lead-Based Paint Hazards
The heart of the challenge to public health agencies is leveraging action to make privately owned housing leadsafe. Many CLPPPs are increasingly viewing leveraging action to address lead hazards in housing as a part of their leadership role. While public health program directors and staff are clearly the primary audience for Building Blocks, some strategies entail fostering change in other organizations and systems to advance prevention in high-risk housing. The summary of each building block is coupled with an illustration of how the strategy has been implemented and contact information for at least one individual who is knowledgeable about this activity.
Building Blocks has some inherent limitations that deserve note. The information listed in illustrations (partners, resources, constraints) is not comprehensive but rather a citation of specific and strong examples of building blocks. Results of efforts to replicate a given building block will vary depending on individual state and local laws, maturity of partnerships, political will, and the existence and strength of community-based partners. The applicability of a building block selected for implementation will depend on the maturity and capacity of the jurisdiction and its CLPPP. Inclusion of building blocks in this document does not assure that they have been evaluated for their outcome or transferability.

# Organization of Building Blocks
The description of each strategy reflects the template (Appendix A) that has shaped the research and compilation of Building Blocks. The generalized information includes the title, brief summary, potential applications and benefits (including scope of impact), and critical elements such as staffing patterns, other resource needs, institutional capacity, cost and timing considerations, and indication of feasibility of implementation.
At least one real-world illustration amplifies building block descriptions by documenting the scope and particulars of the example in a given jurisdiction or target area; the staffing and other resources utilized; magnitude of its impact; factors essential to implementation; limitations encountered; estimated potential for replication; and specific contact information and references for additional information. The illustrations offer strong examples of how each strategy has been recently implemented but do not provide an inclusive or exhaustive review of all efforts to ever plumb the benefits of the given strategy. This document displays building blocks grouped by the category that best fits their essential contribution:
- An alphabetical index of of the building blocks follows the Introduction.
The internet edition of Building Blocks for Primary Prevention: Protecting Children from Lead-Based Paint Hazards will be available in Summer 2005 through the website of the Lead Poisoning Prevention Branch, www.cdc.gov/nceh/ lead. Through this site, it will be possible to easily select sections of Building Blocks for online review and search by keyword, location of illustration, category, key actor or partner, and similar criteria.

# ILLUSTRATION #2 OF STRATEGY IN PRACTICE
In 2002, the New York Public Interest Research Group (NYPIRG) used data from the health department to issue a report about childhood lead poisoning disparities in New York City. This study was conducted in conjunction with a campaign to pass the new lead poisoning prevention law in New York City that was enacted in February 2002.
NYPIRG was aware that while the number of children poisoned by lead in New York had been declining for years, there appeared to be stubborn pockets of poisoning throughout the city, particularly in low-income neighborhoods. NYPIRG conducted a small area analysis of the data-they first analyzed the data by census block and then aggregated it by ZIP code. The analysis confirmed that there were indeed concentrated pockets of childhood lead poisoning in New York, many of which were located in low-income areas with tracts of substandard housing.
In order to convince City Council members that the existing lead poisoning prevention policy was not working for all of the city's children, NYPIRG decided they needed to illustrate the extent of the disparities in New York

# POTENTIAL OBSTACLES/BARRIERS
In some areas, landlords may continue to be resistant to change or cooperative working relationships with government regulators and/or community-based organizations, despite persistent efforts to engage them. In other instances, landlords may deem necessary efforts "too expensive," setting up adversarial relationships this strategy is supposed to avoid.
Other resource requirements: Appropriate mechanisms for delivery and dissemination of desired educational messages are needed, but the mechanisms can vary dramatically depending on the design of the educational initiative. Typical educational methods include brochures, fact sheets, and web sites. The considerable range of materials already developed on lead safety obviates the need to develop materials, although modifications should be made to incorporate local referral resources. Programs can augment traditional materials with more attention-getting vehicles, such as diaper bags and other promotional items. Any materials used must be accessible and understandable to those who live in high-risk areas, where language barriers and reading levels can present a challenge. Programs will also need data and surveillance information.

# Building Blocks for Primary Prevention: Protecting Children from Lead-Based Paint Hazards Building Awareness and Public Support EXPAND LEAD SAFETY EDUCATION TO EXPECTANT AND NEW PARENTS
Institutional capacity required: Health education initiatives rarely require special authorization.

# Cost considerations:
Adding a new subject to an existing education program is more cost-efficient than implementing free-standing education focused only on lead safety. Printing materials will cost nominal amounts per parent.
Timing issues: Can be implemented anytime Feasibility of Implementation: Variable. Feasibility depends on the availability of people to manage the effort and resources to support it.

# POTENTIAL OBSTACLES/BARRIERS
One potential obstacle is reaching agreement on a specific strategy deemed most effective for the circumstances, as there are so many possible combinations of messages, messengers, delivery mechanisms, and possible target audiences. In addition, it can be uncomfortable to make lead-safety recommendations to parents in communities where resources do not exist to assist families in repairing lead hazards.
A barrier to the effectiveness of education on lead safety is the fact that expectant and new parents may already be overwhelmed with other recent messages on multiple weighty issues and have many other concerns and priorities. Discussion of possible lead exposure in utero may help parents to focus attention on the immediacy of lead safety.
Programs may also encounter unexpected challenges in developing partnerships with seemingly natural partners. For example, one program reported difficulty in convincing obstetricians to participate in such an educational campaign.

# ADDITIONAL RESOURCES N/A

# ILLUSTRATION #1 OF STRATEGY IN PRACTICE
MA CLPPP conducted a project to educate pregnant women about lead hazards and encourage them to adopt preventive behaviors, and to educate doctors and staff members for community health centers and agencies in the target communities. The project's three core activities were:
1. Development and distribution of bilingual prenatal lead awareness kits packaged in large attractive diaper bags. The kit included educational fact sheets and brochures, promotional items, a community resource card, an evaluation card, and a voucher for free lead-safety training for a family member. The pre-existing educational materials were provided as bilingual documents, in English and one other language-Spanish, Khmer, or Vietnamese. On a limited basis, materials were also distributed in Russian, Chinese, and Portuguese. 2. Recruitment of community health centers and agencies that serve pregnant women in the target communities (e.g., WIC, Head Start, etc.) to educate their staffs and clients and distribute information kits; and, 3. Sponsorship of Grand Rounds training (offering CEUs) for physicians and other medical and program staff in the four communities. This project was supported by a nine-month CDC supplemental grant of $100,000. Staffing utilized: Staffing was routinely about 1.25 FTE, but spiked during busy periods associated with trainings and implementation (e.g., about 5 FTEs for a few days).

# Other resources utilized: N/A
Factors essential to implementation: Staff felt that success was dependent on the availability of a full-time project coordinator and-for effective materials distribution and training recruitment channels-on the network of existing contacts in the community. MA CLPPP was able to use existing MOUs with some partners, which expedited administrative processes.
Limitations/challenges/problems encountered: Major challenges were in the areas of deadlines and evaluation. Various administrative factors meant that the program had about seven months to hire staff and complete the project, operating within the constraints of state governmental systems for purchasing. Due to time and realities, the program was limited to a self-reporting evaluation. Logistical constraints, including an interpretation of HIPAA requirements, prevented an evaluation approach involving tracking individual women's names.
Magnitude of Impact/Potential Impact: Approximately 3,500 diaper bags/information kits were distributed in 4 months, with many distributed in high-risk areas; 29 agencies signed Memoranda of Understanding (MOU) and partnered in the project; 138 self-reported evaluation cards were returned from kits; and Grand Rounds attendees gave high evaluation marks.

# Potential for replication: Moderate

# Contacts for Specific Information
Xanthi Scrimgeour Health Education Coordinator 413-586-7525 x1122 or 1-800-445-1255 Xanthi.Scrimgeour@state.ma.us Paul Hunter Director, MA CLPPP 617-624-5585 paul.hunter@state.ma.us

# References for additional information
1. An August 2003 report called "CDC Supplemental Prenatal Grant: Overview and Evaluation" describes the project and its results in detail. The report includes a review conducted with the New England Lead Coordinating Council of similar prenatal lead education activities that had been undertaken in other states.

# ILLUSTRATION #2 OF STRATEGY IN PRACTICE
As part of a nine-month project focused on increasing testing rates for lead among pregnant women in Alameda and Fresno counties and prompting early intervention, CA CLPPP developed, disseminated, and field-tested educational materials for at-risk pregnant women. To this end, brochures were developed urging women to get tested, and explaining how lead gets into the body, how it can affect a baby, and how to create a lead-safe environment. County-specific phone numbers were provided so that women could easily seek medical care and information regarding lead and pregnancy. After completion, 25,000 packets of culturally-appropriate outreach Pediatricians who are knowledgeable about lead safety and healthy homes can provide better health care for children at high risk of toxic exposures, advocate for relevant solutions, and suggest primary prevention tools for parents. A recent study revealed that many pediatricians want to better understand lead exposure and other environmental history components in patients' backgrounds, yet fewer than one in five has any formal training in making inquiries on lead and other chemical exposures.
Medical schools and residency review committees can work to train pediatricians in environmental history-taking to identify possible lead exposures in the home and to help prevent exposure. Integrating such specialized training into required medical education is the easiest method, as most medical schools already require some level of lead poisoning prevention education during pediatric clinical rotations. Some state medical societies may get involved in mandating primary prevention education requirements, and residency review committees will also be involved. Requiring a rotation at a children's hospital, community center, or local health department can give pediatric students even more first-hand experience with childhood lead poisoning and add extra incentives for them to take steps toward primary prevention in their future practices. Additional course offerings on primary prevention and environmental history-taking could also be included in physicians' required Continuing Medical Education (CME).

# Building Blocks for Primary Prevention: Protecting Children from Lead-Based Paint Hazards Building Awareness and Public Support INTEGRATE LEAD POISONING PREVENTION EDUCATION INTO PHYSICIAN EDUCATION CURRICULA
Institutional capacity required: Curricula complete with primary prevention and environmental history-taking education is the main institutional requirement for this strategy.

# Cost considerations:
No additional costs would be incurred if this training on environmental history-taking and lead safety is integrated into existing education and training systems for pediatricians.

# Timing issues: None
Feasibility of Implementation: Very high. Because some lead poisoning prevention is already built into most medical school curricula as all students go through their pediatric rotations, putting more emphasis on primary prevention and environmental history-taking would require only modest adjustments to curricula, with little or no conflict with other course priorities.

# POTENTIAL OBSTACLES/BARRIERS
None identified.

# ADDITIONAL RESOURCES

# ORGANIZE "TOXIC TOURS" FOR POLICY MAKERS DESCRIPTION OF THE STRATEGY
A first-hand look at unhealthy housing conditions can be provided to public officials by organizing a community tour that allows them to visit homes with hazards (and if possible, some that have been repaired) and talk with residents and advocates about the problems and policy solutions. Experience has shown that policy makers can be moved significantly by the personal experience of seeing hazardous conditions first-hand and having face-to face interaction with families directly affected. First-year medical students can also benefit from a "toxic tour."
Community-based organizations in Los Angeles, New Orleans, and Providence have successfully used this strategy to educate and motivate local health and housing officials. This strategy parallels "Child Watch" tours that child advocacy groups have historically conducted to sensitize and challenge elected officials and journalists regarding a variety of problems that children face.

# POTENTIAL OBSTACLES/BARRIERS
It can be quite challenging to convince public officials, especially elected officials, and the media to participate in the tour. Another challenge is ensuring sensitivity to the families who agree to open their homes to the tour. It is a fine line between showcasing the problem and potential solutions vs. unintentionally allowing voyeurism at the expense of low-income families.

# ADDITIONAL RESOURCES N/A

# ILLUSTRATION OF STRATEGY IN PRACTICE
The Los Angeles Healthy Homes Collaborative has found that providing public officials with tours of hazardous housing conditions deepens the understanding and motivation to enforce standards and improve services to affected families.
The Healthy Homes Collaborative is a diverse coalition of community-based and advocacy organizations committed to eliminating environmental health threats to children and increasing health access. The Collaborative enlists families whose homes will be visited, persuades agency and legislative staff to attend, and arranges the itinerary, transportation, and food for the attendees. An opportunity for the group to eat together is important to all allow attendees to exchange impressions, information, and ideas.

# Jurisdiction or Target

# Other resources utilized: N/A
Factors essential to implementation: Because the Collaborative has worked consistently with tenants and earned their trust, the CBO leaders are able to persuade tenants to participate.

# Limitations/challenges/problems encountered:
The logistics of the tour can be challenging. The size of Los Angeles meant that public officials had to commit almost a full day, with the result that elected officials sent their aides instead of seeing the housing conditions first hand. There may be last-minute conflicts that affect a family's ability to be home or disruptions in the tour schedule, so it is advisable to line up 'extra' families who are willing to participate. Another challenge is facilitating the discussion and reactions of participants with diverse political views and perspectives as everyone is in "close quarters" for the tour.
Magnitude of Impact/Potential Impact: Agency staff felt a new sense of urgency from seeing the desperate living conditions of many families and from seeing how hazards persist in units where violations had been cited. Staff of the lead poisoning prevention program have since been more responsive when alerted to families in need by the Collaborative; communication and working relationships between the CBOs and the agencies have improved.

# ILLUSTRATION OF STRATEGY IN PRACTICE
In September 2003, Indianapolis' mayor unveiled a "Top 10" list of city property owners who have been serial code violators. The property owners on the initial list held title to 310 properties throughout the city. The mayor's list, which is updated as needed, serves several purposes. It helps to distribute information on problem landlords, assisting tenants in avoiding structures that may contain dangerous code violations and health hazards while exposing slumlords to the local community. It also helps the city to hold property owners accountable and provides a tool for community leaders seeking to put pressure on property owners to remedy code violations and maintain their properties.
The list is readily available through the city's website, and it has also been publicized by The Indianapolis Star newspaper.

# Institutional capacity required: N/A
Cost considerations: Extremely low cost.
Timing issues: Sustained cultivation of or accessibility to the media is critical; one-time or occasional efforts will be much less effective.

# Feasibility of Implementation: Very high

# POTENTIAL OBSTACLES/BARRIERS
A potential barrier is the reluctance of families to participate because they fear retaliation from the landlord or other consequences. The willingness of families to cooperate with reporters is essential because the personal toll of lead poisoning helps capture the public attention and build political will to change the status quo.

# ADDITIONAL RESOURCES
N/A

# ILLUSTRATION #1 OF STRATEGY IN PRACTICE
In May of 2001, the Providence Journal ran a six-part series on lead poisoning that helped set the stage for new legislation and regulations in the state. A photojournalist at the Journal, John Freidah initiated the idea, but it could not have happened without the commitment of the newspaper, the hard work of the Childhood Lead Action Project, the time and effort of many government officials who educated and provided information to reporter Peter Lord, and the willingness of many families to open their lives to the journalists and the public. Staffing utilized: At the Journal, reporter Peter Lord and photojournalist John Freidah invested more than 6 months of time preparing the series (and Freidah had begun taking photographs at the lead clinic many months earlier in between other assignments in order to bring the idea vividly to the paper's editors). Top editors at the paper worked with them on "designing" the series to most effectively convey the breadth and impact of lead poisoning in the state. At the Childhood Lead Action Project, a community organizer working with the parents of lead-poisoned children helped the parents overcome their fear of participating in the series. Officials at the Rhode Island Department of Health and the Rhode Island Housing and Mortgage Finance Corporation devoted many meetings to helping Peter Lord understand and accurately convey the issues.

# Jurisdiction or Target

# Other resources utilized:
The state health department forged a partnership with the Providence Journal to make public information about properties that have lead hazards. The department had generated a list of houses where children had been poisoned but didn't have the technical capacity to publish it online. By providing these data to the newspaper and by providing yearly updates to the paper, the department has met the public need for information despite its technical limitations.

# ILLUSTRATION #2 OF STRATEGY IN PRACTICE
The Detroit Free Press conducted an in-depth investigation of lead poisoning in Detroit and Michigan that began appearing January 21, 2003. The paper followed the five-day investigative series with continuing coverage throughout the year. The reporting-and the persistent work of state advocates for children's environmental health-resulted in lead poisoning becoming a top priority of the Governor and the state legislature. In addition, the series prompted the US EPA to order the removal of lead-contaminated soil in a Detroit neighborhood near a former lead smelter.

# Jurisdiction or Target Area: Michigan
Primary Actor: Detroit Free Press

# Secondary Actor(s): Get The Lead Out Coalition
Staffing utilized: The Free Press devoted a multi-talented team of reporters to covering this issue over many months. The reporters worked with and wrote about families affected by lead poisoning, investigated and identified systemic shortcomings in the city and state's programs, hired experts to test the soil near industrial sites, and researched how local efforts compared with other cities and states around the country. When state advocates, including the Get The Lead Out coalition in Grand Rapids, became aware of the investigation, they provided information to the reporters about the extent of the problem outside Detroit and the need for statewide leadership on lead poisoning prevention. Both the newspaper and the advocates worked to sustain the impact of the initial investigation by continued coverage of the problem and of the policy initiatives of the Governor and the state legislature.

# Other resources utilized:
The Free Press conducted an analysis of the State Department of Community Health data on elevated blood lead levels to identify the "hot spot" neighborhoods-those with the most lead-poisoned children-and questioned why the state had not been using the data to target prevention and hazard control efforts. The analysis revealed that the single worst hot spot was in Grand Rapids-a finding that changed the political dynamic of the issue within the state by capturing the attention of the legislators in the western part of the state, educating them on the scope of the problem statewide, and motivating them to support new legislation. Because the paper had to sue the state to release the data, this article appeared in July, putting the issue back on the front burner six months after the original series.

# Factors essential to implementation:
The critical factors are a large-circulation newspaper with a commitment to doing investigative reporting, strong advocates who can use the heightened public attention and concern to build political will for policy change, and continuing coverage and advocacy to keep elected officials focused on and accountable for making necessary changes.

# Limitations/challenges/problems encountered:
The main policy-making challenge in Michigan was overcoming the east/west split in the state. The Free Press broadened their focus beyond Detroit and the eastern part of the state at the urging of state advocates. Most legislators had considered lead poisoning a Detroit problem until the Free Press analysis of the data documented the extent of the problem in Grand Rapids and other western areas.
Magnitude of Impact/Potential Impact: While the Governor had campaigned as a champion of children's environmental health, it is clear that the investigative series combined with advocates' work to take maximal advantage of the publicity persuaded the Governor to submit a much stronger action plan much more quickly than would otherwise have been the case. It is likely the legislature would have reacted far more coolly to the Governor's proposals without the series. (The bills currently working their way through Michigan House and Senate would establish a Childhood Lead Poisoning Prevention and Control Commission, impose penalties on landlords who knowingly rent units with lead hazards, provide tax credits for lead hazard control, create a leadsafe housing registry, increase pressure on Medicaid plans to screen enrolled children for lead poisoning, and require labs to report blood screening results electronically.)
Potential

# ADD LEAD SAFETY TRAINING TO WEATHERIZATION PROGRAMS AND PRACTICES DESCRIPTION OF THE STRATEGY
Integrating lead safety into the ongoing work of weatherization program contractors has the multiple benefits of reducing energy costs, improving the indoor climate, reducing lead hazards in the homes treated by the weatherization program, improving the safety of weatherization crew workers and their families, and protecting the safety of residents. Lead poisoning prevention programs can provide training and incentives such as free or discounted HEPA vacuums and personal protective equipment. Options include developing a hybrid training curriculum, adding lead-safe work practices to standards or specifications, expanding monitoring and inspections to address lead safety concerns, offering complete lead-safe work practices (LSWP) training within the weatherization training program, subsidizing risk assessor training, and providing an XRF analyzer for each local weatherization program.

# BENEFITS
The Department of Energy requires its state-level grantees to ensure that weatherization crews complete lead safety training if they will be working on homes built before 1978. This federal requirement prevents any confusion surrounding the need for lead safety training and ensures that all weatherization workers who operate in older homes will understand the consequences of repair and energy measures that may cut, sand, or pry leadbased paint and how to avoid creating lead dust and paint hazards through proper containment, control during the work, and clean up. It is most efficient to have the state weatherization agency condition disbursement of federal weatherization funds on fulfilling the training requirement; the state can also incorporate into standard training any state-specific standards or other information.
Immediate/Direct Results: There will be increased awareness of lead safety among thousands of laborers and contractors. Public Health Benefits: Crews will be significantly less likely to create hazards such as lead dust, lead soil, or deteriorated lead paint during weatherization work that disturbs lead-based paint. Other Indirect/Collateral Benefits: Lead safety capacity is built in the wider community of individuals and community action agencies that may also conduct repair and renovation work using HUD funds or other resources. Transferable lead safety skills will cause laborers who work in weatherization to be careful about paint chips and dust when performing other types of work in older homes in the future. Weatherization program staff gains awareness of potential health risks associated with lead hazards and other housing condition problems. Finally, the initiative helps build capacity among contractors and awareness of lead-safe work practices that will likely transfer to other non-weatherization jobs-when working in older homes likely to have lead based paint.

# SCOPE OF POTENTIAL IMPACT
Nationally, the risk of lead dust hazards will be reduced as weatherization crews treat pre-1978 homes. More than 100,000 homes are treated by weatherization each year, and a significant majority were built before 1978.
Statewide-You can pursue such training at the state, county, or local level. It is most efficient to have the state condition disbursement of federal weatherization funds on fulfilling the training requirement.
Regional (e.g. multi-county)-Many CAP agencies cover City-or County-Wide Neighborhood/Community Specific (Targeted) Population-Very low-income households

# ILLUSTRATION OF THE STRATEGY IN PRACTICE
This program brings subsidized lead safety training to all agencies administering weatherization funds, provides training to workers, ensures at least one individual is trained and licensed as a lead risk assessor, and provides at least one XRF analyzer to each agency performing weatherization work. The program has developed specific policies and procedures to address lead that are more extensive than the federal requirements. Each weatherization program's risk assessor tests the lead content of the paint likely to be disturbed by the weatherization project in all pre-1978 homes. Using an XRF takes the guesswork out of the job: the crew knows if there is lead paint and does not have to presume it exists. The state pays expert consultants to work with each risk assessor on using the equipment and procedure properly in order to guarantee consistent performance.
Jurisdiction or Target Area: Indiana.
Primary Actor: Division of Family and Children, Housing and Community Service in the Department of Family and Social Services Agency.

# Secondary Actor(s): N/A
Staffing utilized: The state weatherization program director helped launch and develop the program with support from one key staffer and an independent consultant. It quickly became a relatively small aspect of the staff person's job as details fell into place. A consultant developed the policies and procedures, and Environmental Management Institute, an accredited lead trainer, was contracted to support the risk assessors.
Other resources utilized: Administrative funding from the Section 8 program was used to purchase XRF devices.

# Factors essential to implementation:
The key factor for success is the commitment of state weatherization staff who care about the lead issue and are willing to make it a priority. Limitations/challenges/problems encountered: One challenge is to convince key senior managers at the state level of the necessity of creating systems to incorporate lead safety into weatherization and approval for a centralized procurement for XRFs to substantially reduce the price. Obtaining commitments from local community action agency directors to have their weatherization crews complete the training was another challenge that was overcome by the state's upfront provision of needed resources.
Magnitude of Impact/Potential Impact: Weatherization work is performed using lead-safe work practices in all units that have lead-based paint. XRF testing has allowed the CAP agencies to focus dust containment and cleanup efforts when the surface tests positive for lead. Information developed from the lead testing is now available to future tenants and buyers under the federal lead hazard disclosure requirement.

# Potential for replication:
High. Lead safety training for weatherization crews can be replicated throughout all states in which it is a priority for key managers at the state level.

# ASSESS AND ADDRESS MULTIPLE HAZARDS SIMULTANEOUSLY DESCRIPTION OF THE STRATEGY
Programs that address health hazards beyond lead can efficiently and effectively equip families to reduce health hazards in the home environment. Community-based organizations train community members to assess houses for hazards and leverage the results through both individual and systems advocacy. Such programs also work to build support for prevention through the education of tenants/residents about hazards, available remedies for obtaining safe repairs, legal rights, and leadership skills. Programs focusing on direct services train volunteers and community health workers to conduct home audits, create a personalized Home Action Plan that emphasizes low-or no-cost solutions, and provide tools to assist in making needed changes, such as sealed mattress covers, cleaning kits, and HEPA vacuum loaners.

# BENEFITS
Immediate/Direct Results: Home heath hazards will be identified. Rental property owners, their tenants, and owner-occupants will learn low-cost solutions to address hazards and be aware of home health hazards. Public Health Benefits: Written reports and photographs that are property-specific inform the landlord about hazards. With respect to lead, the landlord then must correct the problem or disclose this information to prospective tenants. Property-specific data transforms the federal lead hazard disclosure rule's right to know into a powerful catalyst for action to improve conditions in substandard rental properties. Aggregate data can motivate local lawmakers to address the prevalence of hazards through property maintenance codes, health and housing codes, and other policy changes.
Other Indirect/Collateral Benefits: Fosters community building and community organizing. Advocates can use aggregate data to generate media interest in the plight of low-income families who seek healthy housing.

# POTENTIAL OBSTACLES/BARRIERS
If home assessments reveal health hazards in rental housing, steps must be taken to ensure that tenants are protected from retaliatory evictions and other illegal landlord actions. Advocates must also guard against the responsibility being inappropriately shifted from landlord to tenant. Advocates must press code inspectors to inspect, cite, and enforce the code.

# ADDITIONAL RESOURCES

# N/A

# ILLUSTRATION #1 OF STRATEGY IN PRACTICE
The American Lung Association of Washington established the Master Home Environmentalist (MHE) program in 1992 and has trained more than 1,400 volunteers. Trainers include environmental scientists, psychologists, social workers, academics, and medical professionals. Volunteers complete 35 hours of training and 35 hours of community service. Trained MHE volunteers use a Home Environmental Assessment List (HEAL TM ) to help identify health hazards in the home, including lead, dust, and mold. The volunteer then works with the resident to develop an action plan to create a healthier home environment, emphasizing inexpensive or no-cost solutions.
Jurisdiction or Target Area: King County, Washington; expanding to additional counties.

# Primary Actor: American Lung Association of Washington

# Secondary Actor(s): N/A
Staffing utilized: At a minimum, one full-time staff person is needed to recruit volunteers and members for the steering committee, schedule trainings, etc.
Other resources utilized: Computer, LCD projector for presentations, and trainings are helpful.

# Factors essential to implementation:
Developing key partners to serve as trainers and on the steering committee is essential. The expertise of key partners depends on the geographical area and the type of classes needed; for example, pesticide experts must be recruited where pesticides are a main issue.
Limitations/challenges/problems encountered: Funding and volunteer retention were both challenges.
Magnitude of Impact/Potential Impact: From 1994 to 1999, MHE volunteers reported completing more than 4,500 hours of community service and 1,400 home assessments. A 1997 study revealed that 86% of households visited by MHE volunteers improved their home environment.

# Potential for replication:
Moderate. MHE sells its trademarked and licensed program. Purchasers receive the Implementation Guide, training manual, facilitator's guide, HEAL paperwork, database to track volunteers and residents, as well as all components created by other licensees. The cost is $2,500 for an American Lung Association affiliate; the cost is higher for non-affiliates.

# Contact for Specific Information
Aileen Gagney Environmental Health Program Manager 206-441-5100 agagney@alaw.org

# Building Blocks for Primary Prevention: Protecting Children from Lead-Based Paint Hazards
Building Capacity for Lead Safety BROADCAST LEAD SAFETY TRAINING WIDELY Timing issues: This strategy could be implemented at any time.

# Feasibility of Implementation:
High. In states or regions of states where widespread telecommunication delivery systems exist, this strategy should be feasible. Some limitations may exist.

# POTENTIAL OBSTACLES/BARRIERS
There should be few, if any, potential barriers to implementation of this strategy. Hands-on portions of the training will be nearly impossible to conduct using this strategy, which could limit the value of this particular type of lead-safe work practices course.

# ADDITIONAL RESOURCES N/A

# ILLUSTRATION OF STRATEGY IN PRACTICE
The Iowa Department of Public Health Bureau of Lead Poisoning Prevention (the Bureau) partnered with the Iowa Department of Economic Development, Iowa's housing agency, public housing authorities, and entitlement cities to produce and deliver a lead-safe work practices training curriculum that could be broadcast to workers who were widely scattered throughout rural and urban Iowa.

# Building Blocks for Primary Prevention: Protecting Children from Lead-Based Paint Hazards
Building Capacity for Lead Safety BROADCAST LEAD SAFETY TRAINING WIDELY Limitations/challenges/problems encountered: The main challenge to implementation was coordination of training materials, Bureau staff, and the training schedule. However, Bureau staff noted that this became easier as time passed.
Magnitude of Impact/Potential Impact: 1,020 landlords and contractors were trained via the ICN.

# Potential for replication:
High. This strategy can be easily replicated in any state or multi-county region with a fiber optic or other telecommunications presentation and delivery system.

# ENSURE THAT DO-IT-YOURSELF REHABBERS ARE TRAINED DESCRIPTION OF THE STRATEGY
Housing agencies that provide funds for housing rehab can require that property owners be prepared to effectively deal with existing conditions as well as problems that emerge as they work. Rehabbers of older housing especially need to know how to work safely around lead-based paint and how to safely and thoroughly repair lead-based paint hazards. Rehabbers also need to be aware of the U.S. Environmental Protection Agency's Pre-Renovation and Education Program (406b), which requires property owners to notify all occupants in pre 1978 housing units of any rehab work that will disturb more than two square feet of a painted surface.

# BENEFITS
Immediate/Direct Results: Training do-it-yourself rehabbers will make it more likely that lead-safe work practices will be used. This will bring a category of properties under the lead-safe work practices umbrella that has been missed through other, more formal training of professional rehabilitation contractors. Public Health Benefits: Properties that would not otherwise have had the benefit of lead-safe work practices can now be rehabbed safely. This will reduce or eliminate the creation of lead hazards and encourage the repair of existing hazards, which will decrease children's exposure. Other Indirect/Collateral Benefits: When included as part of a larger housing or development program, this strategy can also help reduce urban blight, reduce other health hazards in older structures, and assist in comprehensive community development and/or revitalization.

# SCOPE OF POTENTIAL IMPACT

# Statewide
Regional (e.g. multi-county) City-or County-Wide Local Community Specific (Targeted) Population

# PRIMARY ACTORS KEY PARTNERS
Housing Agency Property Owners

# CRITICAL ELEMENTS
Staff requirements: This strategy will require staff time to conduct trainings. This could require up to 1.5 FTE if staff training is provided directly by the funding agency. The agency could also contract with outside trainers.
Other resource requirements: Lead-safe work practices training materials will be necessary for this strategy.

# Institutional capacity required:
Training instructors should be well versed in lead-safe work practices.
Cost considerations: This strategy should be cost-effective in preventing health problems.
Timing issues: This strategy would require some short-duration outreach, but it can be implemented at any time. It is also important to implement this strategy in a sustainable way so as to not limit its effectiveness.

# Feasibility of Implementation:
Very high in almost all jurisdictions.

# POTENTIAL OBSTACLES/BARRIERS
Few, if any, barriers should exist for this strategy.

# ADDITIONAL RESOURCES

# Secondary Actor(s): N/A
Staffing utilized: NJ Citizen Action tries to include guest speakers, such as attorneys, pediatricians, or parents of lead poisoned children, to avoid the monotony of a single speaker and to provide expert information.
Other resources utilized: Each trainee receives a large binder full of relevant reference materials, including transparencies for use with overhead projectors and a script on lead poisoning designed to make it easier for attendees to become trainers. The training includes lunch.
Factors essential to implementation: NJ Citizen Action staff believe that the most essential factor to continued success of the training is the quality of the training, as attendance would surely fall off if agency managers and CBOs did not perceive value in dedicating a full day of a new staff member's time. Keeping logistics routine enables program staff to focus more on recruiting and providing quality training and outreach than on, for example, catering or parking arrangements.
Limitations/challenges/problems encountered: None listed.

# Magnitude of

# POTENTIAL OBSTACLES/BARRIERS
The obstacles to delivering a lead-safe work practices training to non-English speaking immigrant communities are many and varied. Skilled, culturally-competent trainers are need to teach the Spanish version of the HUD EPA course Lead Safety for Remodeling, Repair and Painting. The course has not yet been translated into languages needed by non-Spanish speaking immigrants who may also be working as day laborers and at risk for lead hazard exposure. Since many immigrants may not have been able to attend school in their country of origin long enough to equip them to sit through a long, classroom-style training, delivery needs to be paced or staged and include hands-on practices.
The main obstacle to getting day laborers to use lead-safe work practices is that the relationship between day laborers and their employers is not conducive to the workers changing work methods based on law and safety. Simply providing a training opportunity for workers is not enough-employers must be motivated or required to comply with lead safety requirements. Factors essential to implementation: In Los Angeles, healthy homes advocates have found that several steps are needed to successfully deliver the Spanish-language version of the lead-safe work practices course to day laborers. Most day laborers are unable to give up a full 8-hour workday in order to attend training for which they are not compensated. Therefore, advocates have divided the training into several evening sessions. Second, trainers emphasize the self-protective benefits of lead safety, since linking the issue to worker protection has been an important step in engaging day laborers in the issue of lead-safety and in how to prevent hazards in the first place. Third, using written materials as little as possible, and relying on face-to-face explanations and handson use of equipment has been the most successful teaching method.

# ADDITIONAL RESOURCES

# Limitations/challenges/problems encountered:
The main barrier to getting day laborers to use lead safe work practices is the employer. Given the scarcity of work for a growing population of workers, day laborers are unwilling to raise concern over lead safety with their employers, if they are even aware of this issue. Community and union organizers need to support workers in protecting themselves and their families by "blowing the whistle" on employers circumventing lead safety laws in order to get work done as quickly and cheaply as possible without regard to the health and safety of either the family whose home is being painted or repaired or the family of the worker.

# Magnitude of actual impact:
The project trained 200 workers in one year. Since a typical day laborer works on an average of 50-100 homes annually, this training has added lead-safe work practices to thousands of projects.
Potential for replication: Moderate. Replica (modified) projects have or are being carried out in several other immigrant communities in the United States, including the Mission District in San Francisco, CA. Every "replication" of this project will vary due to local political, population, and socio-economic variances. This project can most successfully be replicated where lead-safe work practices are required during painting and remodeling activities.

# Contacts for Specific Information

# CRITICAL ELEMENTS
Staff requirements: The resources required are somewhat related to the scale of the project. In a city or county, an existing weatherization program could partner with a lead hazard control program and, with a percentage of a full time employee's time, structure a project to target weatherization units for lead hazard control. If a broader effort is envisioned to add a lead hazard control element to statewide weatherization or rehab programs, a more substantial commitment of staff resources and funding would be needed.

# Building Blocks for Primary Prevention: Protecting Children from Lead-Based Paint Hazards Building Capacity for Lead Safety EXPAND WEATHERIZATION AND REHAB PROGRAMS TO ADDRESS LEAD SAFETY
Other resource requirements: The weatherization program would need equipment and trained personnel to conduct lead inspections and/or risk assessments (to confirm the presence of lead based paint) and perform dust clearance testing. They would also need access to trained and qualified contractors to perform the work.
Institutional capacity required: Typically it is not necessary to change laws or regulations to integrate the delivery of weatherization and lead hazard control services. The main capacity issue is the availability of qualified personnel to perform the hazard assessments (or measure lead content in paint), complete the work following lead safety standards, and conduct clearance tests. Weatherization and rehab programs can have their existing crews perform lead hazard reduction provided they are properly qualified. For abatement projects, workers and contractors must be trained and certified. Except in a few states, training in lead-safe work practices is sufficient qualification for most non-abatement projects. Certified lead inspectors, risk assessors and-in some states-sampling technicians can perform the dust clearance testing after the work is completed.

# Cost considerations:
Leveraging other programs' work in homes to tackle lead hazards is generally cost effective. Weatherization and rehab programs already bear the costs of identifying housing units appropriate for their programs and their eligibility criteria are consistent with risk indicators for lead hazards (homes built before 1950; low-income families). Expanded programs can therefore offer lead hazard control, building upon existing efforts to enroll units and fix other problems, many of which may also be contributing to lead hazards, such as plumbing leaks, holes in the exterior walls or roof, and poor insulation resulting in condensation and water damage. In some cases, it may be appropriate to purchase XRF machines to help identify homes where lead hazard control is not needed.

# Timing issues:
If funding is available to support the lead hazard control interventions, approximately 6-12 months is needed to launch such a program. If funding is not reliable, then a more substantial commitment of staff resources and time may be need to structure the appropriate partnerships.

# Feasibility of Implementation:
Moderate. Implementation can hinge on the availability of dedicated funds to support the added lead work. Weatherization and publicly supported rehab programs generally have production targets that provide disincentives to increasing the costs in individual units. There may also be restrictions on spending the program's funds for actions not directly related to the program's mission (e.g., non-energy based repairs are ineligible for weatherization funding, except that in some states up to 10% can be spent on "health and safety" repairs). A key to implementation therefore is locating funds that can be used for lead work and securing a commitment from the state and local housing and weatherization program managers that this supplemental work is a valuable complement to their central mission.

# POTENTIAL OBSTACLES/BARRIERS
Lack of support from the key energy or housing agency staff and/or the local or state lead program can hinder efforts. Funding for added lead work must be secured.

# ADDITIONAL RESOURCES N/A

# ILLUSTRATION OF STRATEGY IN PRACTICE
The Department of Public Health supplements weatherization activities in pre-1978 housing with a child under age six to include targeted lead hazard control activities. Window wells are capped and a thorough cleaning of windowsills and floors is completed using a wet wash and HEPA vacuum. Pre-and post-intervention dust samples are collected to document the decline in lead-contaminated dust and to verify that the unit meets dust clearance standards. Clearance testing is performed by certified lead risk assessors. Funding for the lead supplement to the weatherization is provided by a HUD-funded lead hazard reduction grant. Factors essential to implementation: Funding such as support from the state or regional weatherization program and the HUD lead hazard control grant program or other sources to underwrite the lead treatments is key. Another potential source of funding could be state energy consortiums that are funded by electric utilities to help justify window treatments. The weatherization program must also have policies to ensure the appropriate lead training, work practices, and that clearance testing occurs.

# Limitations/challenges/problems encountered:
The most difficult aspect of the program is managing the logistics of the various components. A second challenge is the inherent difficulty in proving that such prevention-based action works. The program did not have funds to collect data to document this. Finally, the majority of homes treated by a typical weatherization program are not occupied by a family with a young child.

# Magnitude of Impact/Potential Impact:
The program targets neighborhoods and homes with key risk factors for lead hazards (older homes built before 1950; low income families which are eligible for weatherization services). To date the program has completed the lead treatments in 61 units, all of which had at least one child under age 6. Slightly more than half of the units were owner-occupied. Health department staff believes that this initiative has helped prevent elevated blood lead levels in units where work occurred. None of the homes were occupied by children with elevated blood lead levels when this work occurred. Contractors performing weatherization now understand how to complete lead dust removal during final cleanup and recognize the importance of controlling lead-contaminated dust. These changes in cleaning behavior extend to jobs in older homes even when there is not a lead specification.

# BENEFITS
Immediate/Direct Results: Property owners will be provided additional opportunities to be trained in leadsafe work practices. Public Health Benefits: As more property owners are trained in lead-safe work practices, creation or exacerbation of lead-based paint hazards will decrease, lowering the risk of childhood exposure to lead hazards.
Other Indirect/Collateral Benefits: If required for property owners cited for code violations, this strategy can provide a useful, alternative enforcement mechanism. Instead of levying fines which may never be paid, an enforcement agency can put primary prevention tools in the hands of those who need them most.

# SCOPE OF POTENTIAL IMPACT

# CRITICAL ELEMENTS
Staff requirements: This strategy is not staff-intensive. An experienced trainer will be needed one or two days a month.
Other resource requirements: Lead-safe work practices training materials will be necessary.

# Institutional capacity required:
Where applicable, instructors certified or accredited in lead-safe work practices training will be required.
Cost considerations: This strategy will incur modest costs by running an ongoing training program. Costs to property owners will be minimal or non-existent.

# POTENTIAL OBSTACLES/BARRIERS
Tying lead-safe work practices training to code enforcement may prove to be a challenge in some jurisdictions, as enforcement agencies may prefer to rely exclusively on fines. There may also be a lack of interest in ongoing training programs on the part of property owners, or a lack of time to attend such training.

# ADDITIONAL RESOURCES

# Potential for replication:
The potential for replication is high.

# Contact for Specific Information

# PROVIDE TECHNICAL ASSISTANCE TO PROPERTY OWNERS DESCRIPTION OF THE STRATEGY
Cities, states, and community-based organizations can provide technical assistance to property owners who are seeking to meet lead-safe housing and lead hazard control requirements or to voluntarily implement lead safety measures. As a complement to relevant training in lead-safe work practices and regulatory requirements, individualized technical assistance can accelerate the pace at which property owners and contractors retool the way they work. Depending on the scope of the strategy, technical assistance can be accessible through a hotline, one-on-one visits at a "one-stop" center, or a user-friendly interactive website. In the process, these agencies, which may normally be seen as antagonistic toward property owners, will learn about the issues and needs facing the owners of high-risk housing and be able to address gaps in their understanding of lead safety. Also, the property owners will be better positioned to successfully assume their role as partners in the effort to prevent childhood lead poisoning.

# BENEFITS

# SCOPE OF POTENTIAL IMPACT
Statewide City-or County-Wide

# Regional

# PRIMARY ACTORS
Health Department Housing Agency

# KEY PARTNERS
Property Owners Homeowners Community-based Organizations

# CRITICAL ELEMENTS
Staff requirements: Staff requirements will vary substantially based upon the scope of the strategy. Some small projects may only require 1-2 FTE, while larger projects may need a staff of 6 or more FTE to properly engage property owners on an individualized basis.

# Other resource requirements: N/A
Institutional capacity required: This strategy requires staff knowledgeable in lead safety and state and federal lead standards. Staff members with the ability to relate to and work cooperatively with property owners are also essential.

# Cost considerations:
Costs to administer this strategy will depend on scope, but could be significant due to the individualized nature of the strategy. The largest costs to the agency or organization implementing the strategy will come from staff salaries.

# Timing issues:
There are no distinct timing issues with this strategy.

# POTENTIAL OBSTACLES/BARRIERS
The main potential obstacle or barrier to implementing this strategy will be a lack of funding for project staff. States and localities with tight budgets will need to look for creative funding mechanisms to implement their specific technical assistance projects.

# ADDITIONAL RESOURCES N/A

# ILLUSTRATION OF STRATEGY IN PRACTICE
Rhode Island's Lead Hazard Mitigation law requires the state to provide technical assistance to property owners who seek to comply with the law requiring the repair of lead hazards using lead safe work practices and clearance. The Housing Resources Commission is charged with crafting and implementing a technical assistance plan. When the plan is fully implemented, the state will provide property owners with access to technical service centers. These centers will be "one-stop shops" where owners will be able to gain hands-on experience with lead hazard mitigation, work one-on-one with technical assistance staff, and find resources on how to obtain financial assistance for making their properties lead-safe. It is anticipated that the state will have these centers in place by July 1, 2005.

# Jurisdiction or Target Area: Rhode Island

# Primary Actor: Housing Resources Commission

# Secondary Actor(s): N/A
Staffing utilized: To fully implement the program, the Housing Resources Commission estimates it will need 6 FTE.

# Other resources utilized: N/A
Factors essential to implementation: Factors essential to implementation include the ability to secure funding for technical assistance staff, as well as property owners' use of the technical assistance resources.
Limitations/challenges/problems encountered: Without funding, the Housing Resources Commission will not be able to retain sufficient technical assistance staff.

# Magnitude of Impact/Potential Impact:
The technical assistance plan has not yet been implemented. However, the state expects many property owners to use its technical assistance resources as they work to meet the requirements of Rhode Island's lead hazard mitigation law.

# Potential for replication:
Given the availability of professionals able to provide technical assistance regarding lead-safe work practices and lead hazard control, this strategy is fairly easy to replicate.

# Contact for Specific Information
Simon Kue Rhode Island Housing Resources Commission 401-450-1349 www.HRC.ri.gov

# Building Blocks for Primary Prevention: Protecting Children from Lead-Based Paint Hazards
Building Capacity for Lead Safety

# TRAIN AND EMPLOY LOW-INCOME COMMUNITY RESIDENTS IN HAZARD CONTROL DESCRIPTION OF THE STRATEGY
Environmental health services can be provided to communities through programs that train and employ lowincome community residents, including parents of lead-poisoned children and parents of children at high risk.
The services provided can consist of low-cost hazard control, cleaning, peer education, and the provision of products that reduce environmental health hazards. Health departments, housing agencies, and communitybased organizations can work independently or collaboratively to provide these trainings.

# BENEFITS
Immediate/Direct Results: Where demand for services exist, low-income residents will have the opportunity to obtain steady, meaningful employment and will be trained to recognize and control lead hazards in their own homes. These residents will likely relate well to other low-income families in their area, supporting hazard control and peer education efforts. Hazard control and other services will also be available to low-income property owners and tenants who may not have had access to such services in the past. Public Health Benefits: Providing low-cost services like hazard control can increase the number of hazards reduced in a particular community, leading to greater primary prevention of childhood lead poisoning.
Other Indirect/Collateral Benefits: This strategy can help reduce unemployment in a local area and can be one useful tool used to combat poverty. Low-income residents will also gain work skills that they may not have been able to obtain elsewhere.

# SCOPE OF POTENTIAL IMPACT
City-or County-Wide Neighborhood/Community

# PRIMARY ACTORS KEY PARTNERS

# Health Department Property Owners Housing Agency
Tenants Community-based Organizations Parents Community Members

# CRITICAL ELEMENTS
Staff requirements: This will vary on the scope of the strategy. If the project will involve employing lowincome workers, new staff will be required.
Other resource requirements: Trainers, educational materials, and environmental health products may be required, depending on the scope of the strategy.
Institutional capacity required: Some projects undertaken by local government agencies may need prior city council/county board approval.
Cost considerations: Overall costs will depend on the scope of the strategy. Projects that involve employing community residents will have higher costs than those that provide training or environmental health products.
Timing issues: This strategy will require some planning and good organization; projects involving employing community residents will also require some lead time for the hiring process.

# Feasibility of Implementation:
High. This strategy should be feasible to implement.

# POTENTIAL OBSTACLES/BARRIERS
In some areas, projects that involve employing community residents may find a lack of potential employees. Other challenges to this type of project could include employee retention problems.

# ADDITIONAL RESOURCES N/A

# ILLUSTRATION OF STRATEGY IN PRACTICE
Healthy Homes Services is a program of The Way Home (TWH), a non-profit tenant rights and social services agency in Manchester, New Hampshire. The program trains and employs low-income community residents, including parents of lead-poisoned children and children at high risk, to provide environmental health services to their communities. These services, which include low-cost hazard control, peer education, and the provision of products that reduce environmental health hazards, have proven to be one way to advance primary prevention efforts. Other resources utilized: The Healthy Homes Services project was initially launched under a small grant from the U.S. Environmental Protection Agency. Currently, the project is operating as a sub-grantee to the City of Manchester, under a substantial HUD Lead Hazard Control grant. Staff knowledgeable in lead safety, peer education, and training low-income residents have also been utilized by the project.

# Jurisdiction or Target

# Factors essential to implementation:
A dedicated source of funding and interest from landlords and residents have been essential to implementing this strategy.
Limitations/challenges/problems encountered: Reliance on grants and low-interest loans are challenges the project has faced. The project is now seeking to become sustainable through small contracts and offering more services at low cost, which will allow it to operate without heavy reliance on grants.
Magnitude of Impact/Potential Impact: As of the beginning of 2004, the project had trained a total of 31 low-income residents, seven in peer education and 24 in low-cost lead hazard control.

# Potential for replication:
Moderate. Initially, any project similar to Healthy Homes Services will rely on grant funding. With a commitment to use initial grant money to seek out other sustainable funding, this strategy has a high potential for replication.

# Contact for Specific Information
Mary Sliney Executive Director, The Way Home 603-627-5403

# References for additional information N/A
Building Blocks for Primary Prevention: Protecting Children from Lead-Based Paint Hazards

# COLLABORATIONS, PARTNERSHIPS, AND INCENTIVES COLLABORATE FOR LEAD SAFETY IN CHILD CARE HOMES CREATE INCENTIVES TO INTEGRATE LEAD SAFETY INTO HOUSING REHABILITATION INTRODUCE INCENTIVES FOR LEAD SAFETY INTO CHILD CARE PROGRAMS LEND OUT LEAD SAFETY EQUIPMENT SHARE RISK ASSESSMENT AND LEAD SAMPLING SERVICES TEACH CODE INSPECTORS ABOUT LEAD SAFETY THROUGH JOINT VISITS

# COLLABORATE FOR LEAD SAFETY IN CHILD CARE HOMES DESCRIPTION OF THE STRATEGY
Protecting children in child care settings is an essential complement to preventing exposure in the home environment. Using collaborations between local child care providers, associations that represent their interests, and local housing or health agencies can ensure that child care homes (i.e. child care based in the private home of the caregiver) are renovated to provide a lead-safe and healthy environment in which children thrive.

# BENEFITS
Immediate/Direct Results: Participating child care homes will have facilities that are lead-safe and healthier for children. Public Health Benefits: If a child care home has lead hazards, many children may become lead poisoned.
Since the children served may not otherwise be considered at high risk for lead poisoning, they may not be identified under targeted screening programs. Reducing lead hazards in these facilities will benefit all of the children who use the child care homes' services. Awareness of healthy homes approaches in the properties where their children spend time may prompt parents to consider like measures in their own homes. If child care homes are similar to all homes, they are almost twice as likely to have lead hazards than a licensed, non home-based child care center.
Other Indirect/Collateral Benefits: The owners of child care homes may be reluctant to address lead hazards given competing priorities. If competitors are marketing their lead-safe and healthy status, they may be more likely to address the issue. They may also be more willing to accept a lead-safe mandate if industry leaders have a model for success to allay fears.

# SCOPE OF POTENTIAL IMPACT
There are 14,200 licensed non-home-based, child care centers nationally. There may be as many as ten times more child care homes that are not licensed.
City-or County-Wide Neighborhood/Community Specific (Targeted) Population-The approach may be expanded to non-home based child care centers but HUD funding may be more limited.

# PRIMARY ACTORS KEY PARTNERS
Housing Agency Health Department Child Care Providers Community-based Organizations Property Owners Parents

# CRITICAL ELEMENTS
Staff requirements: One FTE will be needed to establish and manage the program and conduct outreach to the proprietors of child care homes. The amount of time depends on the number of providers to be solicited to participate in the program. A small community might not need a full-time person while a large area with many unlicensed child care homes may need more staff.
Other resource requirements: A strong association representing the child care providers, especially the homebased providers, is extremely helpful. The association can market the opportunity and provide the basic education needed to have willing and able participants.

# Building Blocks for Primary Prevention: Protecting Children from Lead-Based Paint Hazards Collaborations, Partnerships, and Incentives COLLABORATE FOR LEAD SAFETY IN CHILD CARE HOMES
Institutional capacity required: Qualified personnel are needed to check for hazards and make repairs. In many states, a lead sampling technician can check for deteriorated paint and lead dust hazards. If the home is pre-1950 or lead hazards are suspected, a risk assessment should be performed to check for hazards and determine what is needed to make the property lead-safe. It would be beneficial if the sampling technician or risk assessor were familiar with asthma triggers and methods to reduce those sources since asthma is a significant concern for most child care providers. Contractors or workers trained to perform lead hazard control will be needed to perform the work. After work is completed the property must pass a clearance test (performed by a sampling technician in the 23 states where they are clearly authorized, or by a risk assessor).
Cost considerations: Grant or loan money will probably be needed to fund the lead hazard control. The agency that administers the locality's funds from HUD's Community Development Block Grant program is a possible source of funding. Funds awarded by HUD's HOME, Healthy Homes, LEAP, and Lead Hazard Control Programs can also be used for child care homes if the household is income-eligible.

# Timing issues:
The program can begin quickly once funds are secured. While a collaborative team of stakeholders could be formed after funds are available, the team may have to be established in order to demonstrate capacity to implement the program and secure funding. Child care providers are busiest-and therefore unavailable-during August and September when children return to school and establish enrollment. Work may be scheduled during provider vacations to reduce relocation costs.

# Feasibility of Implementation:
Moderate. The program is feasible if grant or loan funding is available. Expanding beyond lead hazards to address asthma triggers such as mold, cockroaches, and dust mites may increase acceptance by meeting the growing concern to families and caregivers. Therefore, the program needs to be able to deal with the most relevant mix of addressable environmental hazards. Relocation of the provider's family and the child care business to a temporary location may need to be addressed.

# POTENTIAL OBSTACLES/BARRIERS
If communities do not have a broader program to educate potential clients to consider lead safety and healthy homes issues in the selection of a child care home, the broader impact from competition will be lost.  Limitations/challenges/problems encountered: Funding must be available for the work.

# ADDITIONAL RESOURCES
Magnitude of Impact/Potential Impact: 125 home-based, child care homes were made lead-safe. 70 homebased, child care homes had reduced asthma triggers.

# Potential for replication: Very high.

# Contact for Specific Information
Ed Petsche HEEL Coordinator 612-349-0563 leadpro@gmdca.org

# References for additional information
1. Greater Minneapolis Day-Care Association www.gmdca.org

# ILLUSTRATION #2 OF STRATEGY IN PRACTICE
The program is designed to improve the quality of 25 home-based child care providers serving more than 150 children in Rochester and Syracuse by making them lead-safe and addressing other healthy homes and general safety issues. To avoid disruption to services and protect the children who attend the homes, the program is providing temporary relocation to an alternative location while renovations are underway. The program educates providers and parents using their services on lead poisoning and daily maintenance techniques to reduce lead hazards and other environmental hazards. It is designed to serve as a model for other communities. Potential for replication: Very high. The project is producing an implementation guide and document templates so it can be replicated in other communities. Funding must be available for the lead hazard control work.

# Jurisdiction or Target

# Contacts for Specific Information

# SCOPE OF POTENTIAL IMPACT
City-or County-Wide-Can apply to jurisdiction of county or city health department Neighborhood/Community-Can target specific neighborhoods

# PRIMARY ACTORS KEY PARTNERS
Health Department Housing Agency Community-based Organizations Contractors

# CRITICAL ELEMENTS
Staff requirements: The staffing needs are minimal.
Other resource requirements: If lead inspections are provided, XRF analyzers will be needed.

# Institutional capacity required:
State regulatory agencies must take a flexible, practical approach to incorporating lead hazard control into rehab projects. Requiring abatement certification exceeds HUD requirements and may unnecessarily increase the cost of smaller rehab projects. Communities need a combination of certified workers and workers trained in lead-safe work practices to perform large-and smallscale rehab projects respectively.
Cost considerations: First, rehab costs will increase incrementally as a result of contractors using safe work practices and for minor activities such as additional set-up and clean-up steps. Ideally, another funding source should be made available to help pay the additional costs of lead hazard control that are above and beyond the scope of the rehabilitation work. Alternatively, health departments might charge fees to the housing agency for performing lead inspections or risk assessments, as well as training contractors and workers, to support the continuation of skilled staff.

# Timing issues:
The health department and the housing agency need to agree on the timing of the risk assessment, the housing inspection, and the development of specifications. There are many different approaches, which basically fall into two camps. The first is to develop the rehab scope of work which is then given to the risk assessor. The risk assessment will then suggest additional work required by the risk assessment and specific work practices that should be followed during the rehab. The second is to conduct the risk assessment first so that all lead hazard control work can be incorporated into the rehab scope of work from the outset. Either approach can be effective, but there must be agreement on protocols before launching a collaborative venture.

# Feasibility of Implementation:
High. This primary prevention strategy can be implemented in communities where there is an interest and a will to make it work. Effective strategic planning for preventing childhood lead poisoning can foster such resource sharing between housing rehab programs and CLPPPS.

# POTENTIAL OBSTACLES/BARRIERS
Individual state regulations and requirements can be a barrier. State policy must be flexible while maintaining consistency on basic principles. In addition, a state or local requirement for lead hazard insurance can present an obstacle to getting contractors to perform rehab work.

# ADDITIONAL RESOURCES
1. www.hud.gov/offices/lead/leadsaferule/index.cfm

# ILLUSTRATION OF STRATEGY IN PRACTICE
The Health Department performs a range of services for community development corporations conducting housing rehab using federal funds. It performs risk assessments, specifies the scope of work for lead hazard control which is incorporated into the rehab specifications, conducts post-work clearance examinations, trains workers in lead-safe work practices (LSWP), and provides up to $2,000 per unit in matching funds for rehab projects. This broad spectrum of services constitutes a powerful incentive for the public and private rehabilitation industry to address lead hazards using lead-safe work practices. Timing issues: It will take 6-12 months to establish the program, build support for it, and develop materials. Full implementation usually will take an additional year. Child care facilities are busiest-and therefore unavailable-during August and September when children are returning to school or enrolling.

# Jurisdiction or Target

# Feasibility of Implementation:
Moderate. The program is feasible but to reach the child care facilities most in need of support and oversight, the program should ideally to be part of a larger effort to improve health conditions within all child care facilities. In addition, the program is difficult to implement if narrowly focused on lead hazards. Most child care facilities view asthma triggers such as mold, cockroaches and dust mites as a bigger concern. Therefore, services that address a broad mix of environmental hazards will be more readily accepted.

# POTENTIAL OBSTACLES/BARRIERS
Lead hazards are most effectively addressed in the context of a broader evaluation of environmental hazards, especially mold and moisture; pests and pesticides; and carbon monoxide.
Communities need to be prepared to identify potential resources to address lead hazards and provide technical assistance to help facilities obtain and use those resources.

# ADDITIONAL RESOURCES

# ACCESS ELECTRIC UTILITY PUBLIC BENEFIT FUNDS DESCRIPTION OF THE STRATEGY
Over the past decade, the deregulation of the electric utility industry has prompted the creation of public benefit funds in many states. The funds, which total more than $1.5 billion, support a wide range of activities related to energy conservation including home improvements that produce energy savings, such as increased insulation, air infiltration reduction, and sometimes window replacement. Policies are set by the state energy-related agency through negotiations with the key funding source(s).
Because such funds often target lower income households who suffer disproportionately from lead hazards the synergies are intriguing. The challenge is that these funds often strictly focus on energy and efforts to broaden the eligible activities could be perceived as diluting the programs' purpose. As a result, few utility benefits programs are currently factoring lead hazard reduction considerations into the program design.

# BENEFITS
Immediate/Direct Results: Reducing lead hazards in the course of projects to make energy conservation improvements will have a direct impact on reducing lead exposure in high-risk properties. Such action can prevent lead poisoning and control lead hazards in the home. Public Health Benefits: Repairing lead hazards through window replacement or repair and correction of moisture problems can reduce lead exposure and help to alleviate or prevent mold, which can exacerbate respiratory problems.
Other Indirect/Collateral Benefits: These actions can improve the overall building quality and energy usage (e.g., utility bills) making the building more durable and comfortable. Controlling lead hazards can also improve overall building quality, durability, and energy efficiency.

# SCOPE OF POTENTIAL IMPACT
Statewide-Requires statewide commitment to make public benefit funds available for health and safety issues.

# PRIMARY ACTORS KEY PARTNERS

# State Energy Agency Housing Agency Utilities
Community-based Organizations

# CRITICAL ELEMENTS
Staff requirements: Short-term staff resources are required to develop the expansion of eligible activities to include lead and other health concerns. Staffing to clarify the actions that are eligible for public utility funding and appropriate protocols and procedures will need to be integrated into existing structures for the administration of public benefit funds.
Other resource requirements: Weatherization program crews may need additional training to check for and repair lead hazards.

# Institutional capacity required:
It is essential that the entity determining the scope and eligible activities for public benefit funds take steps to clarify that lead hazard control activities are eligible for funding. This may require a change in state statutory authority or a policy change by a state commission or entity that oversees the program and/or the utility that is providing the funds through the fee attached to utility bills.

# Cost considerations:
Once a decision is made to expand the use of the public benefits funds, the only cost of implementing the expansion is minimal staff to oversee the lead hazard repair services.
Building Blocks for Primary Prevention: Protecting Children from Lead-Based Paint Hazards Financing and Subsidies ACCESS ELECTRIC UTILITY PUBLIC BENEFIT FUNDS Timing issues: It may take over a year to gain policy agreement to expand the scope of activities funded by the public benefit funds to support lead hazard assessment and repair. If such actions are already eligible then an additional six months to one year is likely needed to get the program up and running.
Feasibility of Implementation: Moderate. Making public benefits funds available for lead hazard control work may require substantial advocacy and planning efforts.

# POTENTIAL OBSTACLES/BARRIERS
A key potential obstacle may be opposition by energy conservation advocates who may be concerned that expanding the scope of eligible activities for funding by public benefit funds will reduce the number of homes receiving energy improvements.

# ADDITIONAL RESOURCES N/A

# ILLUSTRATION OF THE STRATEGY IN PRACTICE
The New York State Energy Research and Development Authority (NYSERDA) administers programs funded by the System Benefits Charge (SBC) on the electricity transmitted and distributed by the state's investor-owned utilities. Originally, the fees for New York Energy $mart were intended to cover energy-related upgrades. Beginning in 2001, the program was expanded to address health concerns. This expansion required a policy decision at the state level to structure the supplemental health and safety component. The program covers up to 50% of the costs associated with energy-efficiency and indoor air quality improvements to a maximum of $5,000 for a single-family unit or $10,000 for a 2 -4 family building. Low-interest loans are available for qualified applicants to cover the balance of the cost of the work. Total funds equal roughly $150 million per year for residential, commercial, and industrial properties combined; $40 million is invested in residential for both market and lower income.

# Jurisdiction or Target

# Staffing utilized:
Once agreement is reached on expansion of eligible activities to include health and safety concerns, the staff resources required to develop protocols and procedures to administer the program are nominal: overall, NYSERDA has one to two FTE working on the New York Energy $mart program.
Other resources utilized: NYSERDA contracted with a separate organization -Conservation Services Group (CSG) -to administer the program, audit energy and health results, process financial incentives, and manage loans. The Building Performance Institute (BPI) was engaged to develop work practice standards. A third entity with significant experience in adult education trains contractors (who are required to obtain training and certification to participate in the program). Contractors pay roughly $1,000 for each level of certification. NYSERDA reimburses the contractor for 75% of the training and certification fees.

# Factors essential to implementation:
Willing utility company and statewide administrator of public benefits funds, and motivated contractors who will pay for training/certification and absorb cost of lost work time to acquire credentials.

# Building Blocks for Primary Prevention: Protecting Children from Lead-Based Paint Hazards
Financing and Subsidies ACCESS ELECTRIC UTILITY PUBLIC BENEFIT FUNDS Limitations/challenges/problems encountered: Quality assurance is difficult. It is challenging to accurately report that the work occurred and determine if the work was performed consistent with program standards. CSG performs limited field inspections (roughly 15% overall) and BPI conducts sporadic field monitoring.
Magnitude of Impact/Potential Impact: In the initial three years of operation, approximately 4,000 homes have received energy upgrades. An unknown number have also received health upgrades to address combustion gases and possibly lead hazards. The average expenditure per unit is $7,500.
Potential for replication: Uncertain. NYSERDA is willing to share its experiences with other states (e.g., effective advertising strategies, standards, training curriculum, and program design materials). Key ingredients include: creating consumer demand for energy, comfort and health upgrades (where consumers are willing to pay for upgrades), varying marketing to target specific market segments, and developing standards to ensure consistent and quality work is performed. Realistic start up once there is agreement of funding is about two years to get the system working well.

# Contacts for Specific Information

# BENEFITS
Immediate/Direct Results: Funds are available to increase the supply of lead-safe housing through the rehabilitation of substandard older properties (resulting in the elimination of lead hazards) and the construction of new housing. Public Health Benefits: Creating decent affordable housing will prevent exposure to lead hazards, especially if priority is given to projects serving very low-income families that are at high risk for childhood lead poisoning.
Other Indirect/Collateral Benefits: Access to decent housing that is affordable to very low-income households and special needs populations enhances the learning and earning potential of the family and improves its ability to pay for health care, child care, and other necessities.

# SCOPE OF POTENTIAL IMPACT
Statewide Regional (e.g. multi-county) City-or County-Wide

# PRIMARY ACTOR KEY PARTNERS
Housing Agency Property Taxation Agency Community-based Organizations

# CRITICAL ELEMENTS
Staff requirements: This will vary depending on the size of the fund and the nature of the activities to be carried out.

# Other resource requirements:
The heart of a housing trust fund is a reliable, dedicated source of funds. A certainty of funds helps maintain an ongoing program that can sustain a production pipeline and maximize other opportunities.

# Institutional capacity required:
A housing trust fund needs to be administered by an agency or organization that is familiar with soliciting, reviewing, awarding, and monitoring grants and/or loans for affordable housing programs. The administering entity also needs to work closely with community-based organizations that understand and can articulate the needs and capacity of the community.

# Cost considerations:
The size of housing trust funds range from less than $100,000 per year to many millions of dollars per year, depending on the size of the jurisdiction and other factors.

# POTENTIAL OBSTACLES/BARRIERS
The greatest difficulty in getting started is mobilizing the support to convince a legislative body that such a fund is needed and that an ongoing allocation of funds is required to make the fund operate effectively. This requires establishing clear cut goals and objectives, creating a coalition of organizations and individuals to support creation of the fund, and identifying alternative funding sources. Feasibility of Implementation: Moderate. Political will, bolstered by the support of some residential property owners, is key to the implementation of a special real estate assessment mechanism, since a vote by either a legislative body and/or the electorate will be required to implement a new tax or other property-based tax. It should be possible to reach agreement to pursue the strategy in numerous jurisdictions, especially where there is concern about the problem of lead poisoning but action is more likely on approaches that require no new funds, staff, or equipment.

# ADDITIONAL RESOURCES

# POTENTIAL OBSTACLES/BARRIERS
Lack of political will is the most significant potential barrier to establishing a special real estate assessment mechanism. In jurisdictions where a referendum is required for revenue-generating measures, the absence of widespread popular support may be a severe obstacle.

# ADDITIONAL RESOURCES

# DEPLOY ENFORCEMENT ORDERS AND GRANT INCENTIVES IN TANDEM DESCRIPTION OF THE STRATEGY
Public financing for the abatement of lead hazards, combined with code enforcement, provides both the carrot and the stick to provide lead-safe housing in high-risk neighborhoods. Landlords are most likely to be "persuaded" to address lead hazards if financial assistance is available to offset at least part of the cost of repairing/replacing windows and other lead hazards. The threat of being taken to court can be a powerful incentive to landlords. Combining code enforcement with financial incentives is especially useful to motivate action by landlords who own multiple high-risk properties and have limited resources.

# BENEFITS
Immediate/Direct Results: Rental units are rendered safe from lead hazards. Depending on the scope of the program, results can range from a few units to an entire neighborhood or neighborhoods. Public Health Benefits: Reduction in childhood lead poisoning. In addition, there is a heightened awareness of childhood lead poisoning and how to prevent it. Other Indirect/Collateral Benefits: An improved standard of habitability: for example, windows that were dilapidated or painted shut become operable.

# SCOPE OF POTENTIAL IMPACT

# CRITICAL ELEMENTS
Staff requirements: Staff requirements will vary depending on the scope of the program and the extent to which activities are performed in-house or contracted out. Post-work clearance must be performed by a trained staff member or contractor who is certified.
Other resource requirements: A good database is critical to efficient operation. Access to standard professional specifications for the scope of work as well as uniform and reliable cost estimates for typical work will help build support from owners and landlords to participate in the program. In addition, for abatement programs, there must be a sufficient supply of trained and qualified contractors.

# Institutional capacity required:
There must be clear legal authority to require owners to correct lead hazards or at least to repair deteriorated paint. In addition, there must be an institutional structure that can enforce code violations. This may be a municipal court or an administrative hearing process that has enforcement authority.

# Cost considerations:
There must be a funding source to support lead hazard control as well as the code enforcement effort.

# Timing issues:
None; the program can be initiated at any time.

# Building Blocks for Primary Prevention: Protecting Children from Lead-Based Paint Hazards Financing and Subsidies DEPLOY ENFORCEMENT ORDERS AND GRANT INCENTIVES IN TANDEM
Feasibility of Implementation: Moderate. Can be implemented wherever the basic requirements are in place: political support, a staff commitment to working with landlords, legal authority, an operating code enforcement program, a skilled workforce, and financial aid to owners.

# POTENTIAL OBSTACLES/BARRIERS
There must be political support to undertake the program and political will to use code enforcement authority to take action against recalcitrant landlords if they don't agree to repair their properties. Landlords can be expected to appeal to political leadership to forego or curtail the program.
Most difficult of all is getting landlords to buy in to the program. First, it is often difficult to find out who the actual owner of a specific property is. Second, it is even more difficult to get owners to come to a public meeting or agree to a private meeting. Third, if the owner does attend, he or she needs to be convinced to participate in the program and to pay for at least a portion of the repairs. The absence of a strategy on how to deal with landlords, including absentee landlords, can constitute a considerable barrier to success. Limitations/problems encountered: Finding the owners/landlords was often very difficult. Getting them to "apply" for a risk assessment was even harder. City staff did mailings to owners and held group and individual meetings. The combination of hard sales in tandem with the threat of code enforcement was needed to win over reluctant landlords, especially since the amount available for window repairs was limited to approximately $2,000 per unit.

# ADDITIONAL RESOURCES
Magnitude of Impact/Potential Impact: Lead hazard control was completed in 800 units in one year. The owners of approximately 50 units were taken through the court system.

# ESTABLISH A REVOLVING FUND TO STRETCH DOLLARS DESCRIPTION OF THE STRATEGY
Instead of making outright grants of funds for lead hazard control projects, jurisdictions can make loans through a revolving loan fund that recycles the original pool of funds. Loans can be amortized or repayment deferred until the property is sold or refinanced. Financing terms can be indexed according to income so that the lowest income homeowners can access funds at very low and even no interest. Permanent revolving funds can be capitalized using an appropriation from the jurisdiction's general fund, a federal grant, or designating the receipts from a specific tax or fee, so that such monies are continuously reserved for a specified purpose.

# BENEFITS

# CRITICAL ELEMENTS
Staff requirements: One full-time person in the assigned agency is needed to set up the program. This includes developing program procedures and guidelines, preparing marketing materials, and establishing agreements with program partners such as health departments, lenders, and community-based organizations. A key policy issue is whether the agency administering the loan fund will manage the program or rely on other partners (banks, community-based nonprofit organizations, etc.) to perform outreach, prepare and process applications, and service the loans. If all work is done in-house, the staffing requirements will vary substantially depending on the volume of loans and the way the program is designed.
Other resource requirements: Program brochures, manuals, operating procedures for lending programs.
Institutional capacity required: There needs to be institutional capacity to make and/or service real estate loans, including knowledge of the industry and experience with lending programs. Ideally, the program is managed by a housing agency that has a track record with other financing mechanisms. Legislative authority and appropriations must create and fund the program; authority to use repayments for additional loans distinguishes revolving funds from one-time appropriations. Capacity to assist owners with applications is important and can be provided by community-based nonprofit organizations, city/county/state staff, or lenders.

# Cost considerations:
A revolving fund must initially be capitalized by designated funds. Annual or regular additions to the fund may be critical to create stability, meet growing demand, and assure continuation of the fund. Fees to process and service the loan and the cost of outreach need to be factored into the plan.

# Timing issues:
A revolving loan fund can be established at any time.

# Feasibility of Implementation:
Excellent if the institutional capacity is in place.

# POTENTIAL OBSTACLES/BARRIERS
Making loans to low-income owners and/or investors in property rented to low-income families is often not a profitable venture. Financial institutions are experienced and efficient in processing loans; however, a bank will probably need an incentive such as a fee unless it is willing to do the work to maintain or improve its Community Reinvestment Act (CRA) rating.
Capacity must also be established to get referrals or generate applications, assist owners with the application process, qualify applicants, and prepare complete applications for whomever processes the application. A state or local agency may be well served by relying on community-based organizations (CBOs) to reach and encourage applications from the owners of highest risk properties.

# ADDITIONAL RESOURCES N/A

# ILLUSTRATION OF STRATEGY IN PRACTICE
MassHousing provides financing to owners of one-to four-unit properties to abate lead-based paint. Lowincome owner-occupants are eligible for loans with 0 percent interest for which payment is not due until the property's sale or refinancing. Nonprofit organizations and "investor-owners" (landlords who do not live in a unit in the property) that own properties that are being rented to income eligible households are eligible for loans that must be repaid in the near term. The maximum loan amounts are: Single-family-$20,000; 2-family-$25,000; 3-family-$30,000; and 4-family-$35,000. Limitations/problems encountered: Massachusetts found that bond funds didn't work well; a State appropriation was much better. The borrower needs to be current on the mortgage, taxes, and utilities.
Magnitude of Impact/Potential Impact: Approximately 200 -300 loans are made each year. Nearly $50 million has been loaned since 1997.
Potential for replication: Very high. There must be a nonprofit network or other means to assist owners in applying and, if the MassHousing model is followed, a bank willing to participate.

# IMPOSE FEES ON REAL ESTATE TRANSACTIONS AND RELATED PROFESSIONAL LICENSES DESCRIPTION OF THE STRATEGY
Imposing fees on real estate transactions and on the licenses of professionals who procure housing, risk management, or lead services can help subsidize the cost of managing public sector systems for lead poisoning prevention. Fees levied on real estate transactions (e.g. for the recording of deeds or tax stamps) and on licenses for professions and disciplines such as real estate agents, insurance agents, lead inspectors, risk assessors, lead abatement contractors, and others can be a source of dedicated income for lead poisoning prevention programs. These types of strategies would be more common at the state level, but enactment and implementation is possible at the county and municipal levels as well.

# BENEFITS
Immediate/Direct Results: New or increased recurring funding sources are immediately created as the fee structure goes into effect. These funds can be used to support primary prevention programs that may have little, if any, funding from other sources. Public Health Benefits: Funds from these fees or surcharges can be used to fund existing childhood lead poisoning prevention programs as well as initiatives that complement efforts already in existence.
Other Indirect/Collateral Benefits: By targeting home purchases and individuals directly involved with buying, selling, and insuring housing, such fees could raise awareness among homebuyers, real estate agents, mortgage lenders, insurers, and others about lead poisoning prevention issues. Such a strategy may also reinforce the responsibility of buyers, agents, and others to ensure that the home involved in a specific transaction is lead-safe.

# SCOPE OF POTENTIAL IMPACT

# CRITICAL ELEMENTS
Staff requirements: Minor to moderate administrative activities would be required at the start-up of a strategy that imposes a fee on real estate transactions or a surcharge on certain professional licenses. It is unlikely that any new staff would be required to implement such fees or surcharges.
Other resource requirements: In the case of professional license surcharges, the agency(s) that oversee the licensing may need to be involved in administering the strategy.
Institutional capacity required: New statutory or code sections, naming the specific real estate transactions or professional licenses involved, must be added, and the agency(s) involved may need to promulgate new regulations to implement the strategy.
Cost considerations: Small start-up costs to the government agencies responsible for the collection of the new fees or surcharges can be expected, but no further costs should exist beyond this transition period.

# Building Blocks for Primary Prevention: Protecting Children from Lead-Based Paint Hazards Financing and Subsidies IMPOSE FEES ON REAL ESTATE TRANSACTIONS AND RELATED PROFESSIONAL LICENSES

# Timing issues: None
Feasibility of Implementation: Moderate. Political will, bolstered by the support of individuals, community and statewide organizations, and those who have been adversely affected by lead poisoning will be key to implementing this strategy. Partnering with professionals in the real estate or insurance worlds who are concerned about or aware of lead hazards in homes would also be useful.

# POTENTIAL OBSTACLES/BARRIERS
The lack of political will to impose a new fee or surcharge is the major obstacle that could block the realization of this strategy. Once put in place, a license surcharge strategy may have to overcome overburdened licensing agencies or inefficient transfer of revenues. A minimal fee on real estate transactions is not likely to face significant implementation barriers.

# ADDITIONAL RESOURCES N/A

# ILLUSTRATION OF STRATEGY IN PRACTICE
In Massachusetts, surcharges are imposed on the annual fees of a variety of professional licenses. These surcharges are imposed on individuals licensed as real estate brokers and property and casualty insurance agents, as well as on mortgage brokers, mortgage lenders, small loan agencies, and individuals licensed to perform lead inspections. The surcharge is generally $25 per license or renewal, though mortgage brokers, lenders, and small loan agencies pay a $100 surcharge. Staffing utilized: 0.5 FTE.

# Other resources utilized: N/A
Factors essential to implementation: The cooperation of professionals impacted by this strategy is key, as is the level of priority each licensing board places on collecting the surcharges. Two additional factors are essential to the continuing implementation of this strategy:
1. The continued existence of the statutory authority contained in the Acts of 1993; and 2. The timely distribution of the surcharges to the Trust Account for disbursement to DPH Limitations/challenges/problems encountered: There have been no major challenges in implementing the surcharge strategy. However, the Office of the State Auditor found that some professions were not being billed for the surcharge in a timely manner in 2000; the responsible agency subsequently corrected the problem, and in 2002, the Legislature mandated that it collect the surcharge in direct connection with the license renewal process.

# Building Blocks for Primary Prevention: Protecting Children from Lead-Based Paint Hazards Financing and Subsidies IMPOSE FEES ON REAL ESTATE TRANSACTIONS AND RELATED PROFESSIONAL LICENSES
Magnitude of Impact/Potential Impact: The surcharge strategy raises about $1.25 million per year for DPH/CLPPP. This gives the department and the program much needed funds to engage in a variety of childhood lead poisoning prevention activities.
Potential for replication: Moderate. In states with sufficient political will, fee-based funding strategies, such as surcharges on specific professional licenses, could be readily replicated.

# Contacts for Specific Information

# IMPOSE TAXES OR FEES ON POLLUTERS DESCRIPTION OF THE STRATEGY
States and local jurisdictions that have appropriate authority can impose taxes and/or fees on corporations that are judged responsible for contributing to the existence of an environmental health or pollution problem, including those companies that have contributed to the existence of lead hazards in housing. The revenue from these taxes and fees can be used to fund primary prevention programs.

# BENEFITS
Immediate/Direct Results: New or increased funding sources are immediately created as the tax or fee structure goes into effect. These funds can be channeled into a variety of primary prevention efforts that may not have other sources of sustained funding. Public Health Benefits: Funds from these taxes or fees can be used to fund either already existing public health programs related to the prevention of childhood lead poisoning, or possibly expand primary prevention efforts to reach a greater number of people.
Other Indirect/Collateral Benefits: By targeting corporations that are responsible for the production of goods that caused indoor lead contamination, a tax or fee on these polluters helps shift the burden away from taxpayers and individuals who are impacted by environmental health hazards.

# SCOPE OF POTENTIAL IMPACT

# CRITICAL ELEMENTS
Staff requirements: Minor to moderate administrative activities would be required at the start-up of a new tax or fee on polluters. It is unlikely that any new staffing would be required.

# Other resource requirements:
The taxing agency must have all information pertaining to the specific corporations or class of corporations upon which the new tax or fee is to be imposed.

# Institutional capacity required:
A new statutory or code section, naming the specific corporation or class of corporations to be targeted with the new tax or fee, must be added. In many states, taxing authority of this nature must be approved on the state level before being implemented by local jurisdictions.
Cost considerations: Small start-up costs to the government agency responsible for the collection of the new tax or fee can be expected, but no further costs should exist beyond this transition period. Costs to targeted corporations will likely be passed onto to retailers, and in turn, to consumers.

# Timing issues:
Because new statutory authority may be needed to implement taxes or fees on polluters, the implementation of the strategy will depend on legislative calendars, committee hearing schedules, and local government meeting schedules. In some areas, some taxes and fees carry "sunset" provisions, meaning they must be reviewed and reauthorized on a periodic basis. In other areas, tax or fee structure changes such as this are permanent.

# Building Blocks for Primary Prevention: Protecting Children from Lead-Based Paint Hazards Financing and Subsidies IMPOSE TAXES OR FEES ON POLLUTERS
Feasibility of Implementation: Moderate. Political will, bolstered by the support of consumers, community and statewide organizations, and those who have been adversely affected are key to the success of efforts to impose taxes and fees on polluters. Some may be opposed to imposing taxes or fees on selected corporations because that might be seen as "bad for the general business climate" in the state or local area. Others may support shifting the burden of financially supporting lead poisoning prevention programs to those directly responsible for indoor environmental health problems caused by lead.

# POTENTIAL OBSTACLES/BARRIERS
The lack of political will to impose a new tax or fee, especially on powerful corporate interests, is the major obstacle that could block the realization of this strategy. Many states and local areas have very strong business lobbies, and targeted corporations themselves may be willing to spend large amounts of time and money to defeat a strategy that would increase their overall costs.

# ADDITIONAL RESOURCES N/A

# ILLUSTRATION OF STRATEGY IN PRACTICE
The Childhood Lead Poisoning Prevention Act was passed in California in 1991. The state act provides funds for county programs to identify children at risk for lead poisoning and to work toward reducing children's exposure to lead hazards.
The program implemented under the act is funded by a fee imposed on corporations that previously, or currently, bear responsibility for the production and sale of lead or products containing lead. This fee also extends to corporations and businesses that are responsible for other sources of lead or that have contributed or continue to significantly contribute to environmental lead contamination (indoor and outdoor). The fee is assessed on each individual corporation based on two criteria:
- The corporation's past and present responsibility for environmental lead contamination - The corporation's "market share" responsibility for environmental lead contamination The two criteria allow for greater fees to be imposed on those corporations that hold a greater responsibility for environmental lead contamination. Magnitude of Impact/Potential Impact: Annually, $12 million is collected for county programs in California via this fee. The impact is significant in that the fees are the main source of funds for the state's Childhood Lead Poisoning Prevention Program and the county-based programs.

# Jurisdiction or Target Area: California
Potential for replication: Moderate. In states and localities where the political will is present, fee-based funding strategies such as this could be readily replicated with a minimal use of resources.

# Contacts for Specific Information

# LEVERAGE COMMUNITY REINVESTMENT ACT FOR LEAD SAFETY AND HEALTHY HOMES DESCRIPTION OF THE STRATEGY
The federal Community Reinvestment Act (CRA) was enacted in 1977 to challenge widespread discrimination in mortgage lending and encourage banks to help meet the credit needs of all segments of their communities, including low-and moderate-income neighborhoods. Banks may provide loans, grants, technical assistance or services to support community development activities that serve low-and moderate-income communities, including assistance with the cost of abating or controlling lead hazards in housing. Banks report relevant activity to their respective federal regulatory agencies which monitor the banks and issue public ratings of the banks' CRA activities in three areas: lending, investment, and services. These ratings affect whether regulators will permit banks to merge or expand. Many banks are therefore open to partnerships with local agencies or community-based organizations that are seeking financing or other support for specific proposals.

# BENEFITS

# CRITICAL ELEMENTS
Staff requirements: Once a financial institution decides to increase lending or make qualified investments in underserved communities, it must develop appropriate agreements, policy guidelines, and operating procedures. Some banks execute contractual agreements with a nonprofit organization to administer the activity and assist in developing processing procedures for loans and establishing program eligibility criteria. These activities may require a significant investment of time and effort, depending on the experience level of and extent of initiative on the part of the lender and the nonprofit partner.
Other resource requirements: It is easiest for the bank to partner with an experienced nonprofit agency operating an effective program that needs added funding or assistance to expand into new areas or activities.

# Institutional capacity required:
The federal legal authority for CRA activity is already established (12 U.S.C. 2901).

# Building Blocks for Primary Prevention: Protecting Children from Lead-Based Paint Hazards Financing and Subsidies LEVERAGE COMMUNITY REINVESTMENT ACT FOR LEAD SAFETY AND HEALTHY HOMES
Cost considerations: The modest cost of operating community lending activities, as an in-house service and/or under contract with a nonprofit partner, counts as a CRA service.
Timing issues: Can be implemented at any time.

# Feasibility of Implementation:
Moderate where there is a bank that is interested in undertaking CRA activity involving prevention of childhood lead poisoning.

# POTENTIAL OBSTACLES/BARRIERS
The typical problem is finding or designing an activity or program that meets the bank's criteria for lending or investment and also provides substantive assistance. For instance, if the CRA activity is lending to abate or control lead hazards, the bank must be willing to discount its loans or make other changes to its lending guidelines to make the loans attractive to borrowers. A reduction of 1% in the interest rate will generally not be sufficient. Many potential borrowers will not have good credit ratings. A modest relaxation of credit standards may qualify a few borrowers that otherwise could not borrow at conventional lending rates. However, it will probably be necessary to supplement lending at below-market rates with grants for a portion of the cost.

# ADDITIONAL RESOURCES

# Other resources utilized: N/A
Factors essential to implementation: The primary factor is a bank willing to participate; i.e., absorb the closing costs in exchange for CRA credits. Secondly, there must be willing landlords who see the remediation of lead hazards as in their interest.

# Limitations/problems encountered:
The biggest problem is getting landlords to participate. They must become part of the solution.

# Building Blocks for Primary Prevention: Protecting Children from Lead-Based Paint Hazards Financing and Subsidies LEVERAGE COMMUNITY REINVESTMENT ACT FOR LEAD SAFETY AND HEALTHY HOMES
Magnitude of Impact/Potential Impact: Borrowing by owners of rental property is made feasible by two factors: The cost of borrowing is reduced when the bank waives closing costs, and the cost or rehab is partially offset by a grant from the County of up to $6,250. Approximately 40 -50 units will be completed with funds from a HUD Lead Hazard Control grant and the First Place Bank subsidy.

# Potential for replication:
This can be replicated in communities with a bank willing to make concessions in their lending in return for CRA credits.

# Contacts for Specific Information

# MAKE THE MOST OF FINES AND PENALTIES DESCRIPTION OF THE STRATEGY
Typically, fines and penalties that government agencies collect revert to the treasury's general fund. Designating a special fund, revolving or otherwise, offers a mechanism for such receipts to be reserved for a special purpose such as lead hazard control or promoting lead safe work practices. Rather than having all taxpayers fund code enforcement and other services that are directed toward a problem few, jurisdictions can charge violators fees to cover costs of inspection, investigation, and enforcement of building codes and other ordinances related to lead hazards and poisoning prevention.

# BENEFITS
Immediate/Direct Results: This strategy allows municipalities, counties, and even states to fund important prevention programs and enforcement actions that may not receive adequate money from the general fund. The revenue generated from designated fines and penalties can then be used to support more code enforcement, training sessions on lead-safe work practices, lead hazard control, and other primary prevention measures. Public Health Benefits: Presumably, with significant penalties in place for violating statutes or codes related to lead hazards, property owners will be apt to follow the rules, thus engaging in lead-safe work practices, reducing lead hazards in homes, and ultimately lowering the chance that children will be exposed to lead. The primary prevention measures funded by fines and penalties from those property owners who don't play by the rules will also reduce children's exposure to lead hazards.
Other Indirect/Collateral Benefits: As word spreads throughout the area affected by the possibility of fines or penalties (i.e. the city, county, or state), property owners, especially landlords, will become more aware of the issues surrounding lead poisoning in children, lead-safe work practices, and reducing and controlling lead hazards in homes.

# SCOPE OF POTENTIAL IMPACT

# CRITICAL ELEMENTS
Staff requirements: Since this income is generated by existing housing, building, and/or health code enforcement programs, no additional staff should be necessary.
Other resource requirements: Implementation would require systems for tracking data on fines and penalties generated from codes, as well as statutes governing lead hazards and lead safe work practices (or other building or housing provisions).

# Institutional capacity required:
Statutory and regulatory authority needed to create the specialized fund and designate the use of the fines and penalties. Code inspection and enforcement staff may need to be trained on how to recognize lead hazards and unsafe work practices if the jurisdiction has not previously focused on these areas.

# Cost considerations:
In almost all instances, no new enforcement agency or staff will be needed. One possible problem is that the cost of compliance as well as fines and penalties may be passed on to tenants; to mitigate this situation, consideration should be given to using some proceeds for targeted rent subsidies as needed.

# Building Blocks for Primary Prevention: Protecting Children from Lead-Based Paint Hazards
Financing and Subsidies MAKE THE MOST OF FINES AND PENALTIES Timing issues: Enforcement, the collection of fines and penalties, and the flow of money from the specialized fund will depend on the workload of the authorized agency.

# Feasibility of Implementation:
High. Local governments are always looking for revenue generators. Since this approach enables a program to be self-funded, holds bad actors accountable, and doesn't require a general tax increase, it should be quite feasible to implement.

# POTENTIAL OBSTACLES/BARRIERS
Landlord associations will resist enactment and enforcement of code provisions for fines and penalties. Overburdened building inspection, housing, and health departments' implementation and enforcement may be lackluster, resulting in a low rate of collection of penalties.

# ADDITIONAL RESOURCES

# Other resources utilized: N/A
Factors essential to implementation: The main essential factor for implementation of this strategy in San Francisco is the cooperation between two sections of the Department of Building Inspection-the Lead Abatement Section and the Administration and Finance Section. Code enforcement and penalty collection officials rely on the City Tax Collector to collect delinquent penalties and on department hearing officers when a penalty is appealed. Underlying all of this is the code authority already in place.

# Limitations/challenges/problems encountered: None listed.
Magnitude of Impact/Potential Impact: On average, the Building Inspection Fund receives between $1.2 and $1.7 million each year from fines and penalties. A portion of these funds is used to support the enforcement of lead-safe work practices standards for exterior surfaces. This is the major source of funding for this enforcement work; no general revenue is used for the enforcement of the work practices standards.

# Potential for replication:
The potential for replication of this approach to the fines and penalties strategy is high. It is relatively easy to administer, and it is easily integrated into existing code enforcement and penalty structures.

# OFFER AN INCOME TAX CREDIT FOR ABATEMENT DESCRIPTION OF THE STRATEGY
One approach to funding lead hazard control outside of general fund appropriations is for governments to offer a credit on federal, state, or local income taxes to property owners who expend funds for eligible activities. A tax credit's advantage of extremely low administrative costs is balanced against the problem that tax credits are difficult to target and frequently provide little or no benefit for very low-income properties that generate little or no tax liability.

# BENEFITS
Immediate/Direct Results: A tax credit is a way to finance the cost of lead hazard control, subject to cost limitations and other operational requirements such as the use of certified contractors. Although income tax credits provide dollar-for-dollar reduction in tax liability at the end of a tax year, up to the maximum amount specified, the funds are not available to pay for the cost of abatement at the time the work is performed. Public Health Benefits: Additional lead-safe houses will expose fewer children to lead hazards.
Other Indirect/Collateral Benefits: Ease of administration.

# SCOPE OF POTENTIAL IMPACT
Statewide City-or County-Wide

# PRIMARY ACTORS KEY PARTNERS

# Property Taxation Agency Property Owners Contractors

# CRITICAL ELEMENTS
Staff requirements: The staffing requirements to implement a tax credit for abatement are minimal. There is the initial need to draft regulations to incorporate the credit into a state's tax code as well as explanatory materials to foster general public understanding. Once the tax credit is implemented, it becomes just another line item on a tax return.
Other resource requirements: There must be a mechanism for verifying that a property for which a credit is claimed has lead hazards and that the work has addressed the lead hazards (through either abatement or interim controls), leaving the property or work area lead-safe at the end of the job. Jurisdictions should specify that the hazard control and hazard determination/clearance work be performed by appropriate trained or certified personnel. There must be a sufficient supply of qualified personnel available to property owners.

# Institutional capacity required:
A tax structure and administrative agency that can fairly administer a tax credit as part of an income tax system.
Cost considerations: It is very difficult to estimate the financial impact of a tax credit for lead paint abatement on a jurisdiction's tax revenue, since it is impossible to predict how many taxpayers will take advantage of this opportunity.
Timing issues: None.

# Feasibility of Implementation:
Extremely easy to implement, but difficult to enact when state and local revenues are constrained.

# Building Blocks for Primary Prevention: Protecting Children from Lead-Based Paint Hazards Financing and Subsidies OFFER AN INCOME TAX CREDIT FOR ABATEMENT POTENTIAL OBSTACLES/BARRIERS
Successfully amending a complex tax code may be daunting for people and organizations normally dedicated to health and housing issues. The tax credit must be large enough to create an incentive for property owners to spend their own money for lead hazard control or abatement. At the same time, the cost must be reasonable enough that it can be borne by the state.

# ADDITIONAL RESOURCES
1. Federal income tax credit legislation for lead abatement is now pending (S. 1228).

# ILLUSTRATION OF STRATEGY IN PRACTICE
The Commonwealth of Massachusetts' "deleading " income tax credit, which has been in place since 1994, offers a model for other states interested in helping residents pay for the cost of abating lead hazards. The owner of a residential property can claim a tax credit equal to the lesser of the cost of deleading, or $1,500, for the containment or abatement of lead hazards, including the replacement of window units. A tax credit equal to the lesser of one-half of the cost of deleading, or $500, is available to offset the cost of bringing the property into interim compliance, using interim control measures, pending full compliance. Several steps are necessary to claim the credit: the property must be inspected by a licensed inspector; the property is then "deleaded" by a MA-licensed contractor; a licensed inspector issues a letter of compliance or a letter of interim control; and the owner files a copy of the inspector's letter with the owner's income tax return. The tax credit is a dollar-for dollar offset for the actual amount spent against taxes owed. Any unused portion of the credit may be carried forward from the year that a credit was first claimed to any of the next seven years. Some activities may be undertaken by a "qualified unlicensed individual" pursuant to State regulations.

# Jurisdiction or Target Area: Massachusetts

# Other resources utilized: N/A
Factors essential to implementation: State legislation is the essential prerequisite. There is no staff dedicated to implementing or enforcing this particular element of the tax code.

# Limitations/problems encountered:
The relatively modest size of the tax credit ($1,500) limits the use of a tax credit as an incentive to undertake lead hazard abatement activities. Since most deleading projects in Massachusetts cost several thousand dollars, the tax credit is seldom the deciding factor in financing the cost of lead hazard remediation.

# Magnitude of Impact/Potential Impact:
The dollar impact on the State is not known.

# Potential for replication:
This can be implemented in any jurisdiction with an income tax and a legislature willing to create a tax credit for the purpose of abating lead hazards. The potential small loss of revenue will be weighed against other competing budgetary interests.

# Building Blocks for Primary Prevention: Protecting Children from Lead-Based Paint Hazards Financing and Subsidies OFFER AN INCOME TAX CREDIT FOR ABATEMENT

# Contact for Specific Information Massachusetts Department of Revenue 617-887-MDOR

# Building Blocks for Primary Prevention: Protecting Children from Lead-Based Paint Hazards
Financing and Subsidies

# PROVIDE LOCAL PROPERTY TAX CREDITS DESCRIPTION OF THE STRATEGY
Local governments could offer a credit on or forgiveness of property taxes to property owners who make expenditures on specified activities such as window replacement, lead hazard control, or correction of other health and safety hazards-just as credits are provided currently in some locales for marginal properties that are substantially improved. A property tax credit could be very narrowly targeted, for example to a single high-risk neighborhood within designated boundaries. While property tax revenue reductions ultimately have the same budgetary impact as expenditure increases, some jurisdictions may find that tax credits are more palatable than increasing local agency budgets. No specific lead paint or health-related property tax credit exists anywhere today, although a bill (HB1039) to create a property tax credit for lead hazard reduction for residential and child care properties was introduced in Maryland in 2004.

# BENEFITS
Immediate/Direct Results: Improvements related to lead safety and other health considerations are far more likely to be made by owners who can recoup some of their costs. Property tax credits provide more direct and immediate benefits to owners of low-income properties than income tax deductions or credits. Making the credit dependent upon independent verification of the work provides an opportunity to build in quality controls. Public Health Benefits: Lead hazard reduction directly reduces lead exposure to children.
Other Indirect/Collateral Benefits: Improvements will generally increase property values and durability of housing, restore vacant buildings, provide employment opportunities, and increase community pride.

# SCOPE OF POTENTIAL IMPACT

# CRITICAL ELEMENTS
Staff requirements: Approximately 1.0 FTE might be needed to process applications and approve repairs for a program in a major jurisdiction. Other administrative aspects of this program probably could be carried out within the existing staffing and budget of any state or local revenue or property tax agency.
Other resource requirements: Some new administrative processes and forms would be needed.

# Institutional capacity required:
Changes in state, county, and local tax law may be necessary, depending on the jurisdiction.

# Cost considerations:
Losses in property tax revenue would be the main cost to a jurisdiction. There would be marginal administrative costs in ensuring that required repairs are actually done and auditing claims to avoid
Building Blocks for Primary Prevention: Protecting Children from Lead-Based Paint Hazards Financing and Subsidies PROVIDE LOCAL PROPERTY TAX CREDITS fraudulent use of the credit. Long-term enhancement of property value may partially offset the lost tax revenue as lead safety becomes valued in the marketplace. Collateral improvements to property condition (e.g., increased energy efficiency, new windows, plumbing and roof repairs) will increase property value and durability, which in turn should increase future property tax revenues and help arrest blight.

# Timing issues:
No seasonal or cyclical considerations other than the fact that policies that reduce tax revenue are more likely to succeed in times of budget surpluses. Timeline to implement depends on the legislative process.

# Feasibility of Implementation:
High. Many jurisdictions provide property tax credits for a wide range of purposes that are deemed socially beneficial (such as credits for low-income, elderly, disabled, or blind occupants; properties used for charitable or educational purposes; historic preservation; substantial property improvements; and even brownfield clean-up). A credit to promote lead hazard control or other health-related housing improvements would seem to have comparable political appeal.

# POTENTIAL OBSTACLES/BARRIERS
Fraudulent use of the credit could occur without proper quality control measures and independent verification of repairs.

# ADDITIONAL RESOURCES N/A

# ILLUSTRATION OF STRATEGY IN PRACTICE
Since state-enabling legislation was enacted in 1996, Baltimore has offered a property tax incentive program for owners who complete substantial rehabilitation (greater than 25% of the initial "assessed full market value" of the property) of landmark designated properties and properties located in one of the city's historic districts. The program is not designed, nor has it ever been used, for lead hazard control or other health-related repairs specifically, although such hazards are often corrected incidentally. The assessed tax of the renovated or rehabilitated property remains at the same level as it was before the start of renovation for 10 years. Credit is for 100% of the tax assessment increase due to the improvements made, and is fully transferable to a new owner for the remaining life of the credit-provided the property is certified by CHAP. Staffing utilized: 1.5 FTE at CHAP run the program. No new staff has been added at the state tax agency or city finance agency, but a tax agency staff person estimates that each agency currently uses as much as 1 FTE staff to do additional data input and record keeping to support this program.

# Jurisdiction or Target

# Other resources utilized: N/A.
Factors essential to implementation: Implementation requires cooperation among CHAP (accepts, reviews, approves applications and projects), city department of housing and community development (construction permits), state department of taxation (calculates value of tax credit), and city department of finance (issues property tax bills).

# POTENTIAL OBSTACLES/BARRIERS
One potential obstacle is opposition to new fees if the dedicated fund is established based on fees and fines. Therefore, the fees must be kept to the minimum needed to establish and maintain the fund, and the basis and justification for the new fund must be clear and convincing, based on facts about housing and health conditions. Second, property owners are likely to object to new or enhanced housing inspections. Public education and outreach must convince decision-makers that (1) inspections are crucial to relieving documented housing conditions that threaten the health and safety of the occupants; and (2) a more professional code enforcement program featuring registration of rental properties, scheduled inspections timed so that property owners can anticipate them, and consistent enforcement processes will provide greater predictability and objectivity as well as accountability for compliance.
Third, the goals of decent housing condition and lead safety must take precedence over zealousness to garner revenues from penalties (to hire more staff to collect more fines, etc.). Orders to comply without financial penalty should be vigorously pursued since in many cases the limited resources of the owner would be better spent on correcting violations rather than paying fines. Fines must be set high enough to motivate property owners to cooperate with enforcement staff as well as preemptively invest in their properties.

# ADDITIONAL RESOURCES N/A

# ILLUSTRATION #1 OF STRATEGY IN PRACTICE
The City of Los Angeles has adopted a housing ordinance that requires that every residential rental property with two or more units be inspected on a scheduled basis, currently once every five years. The housing habitability inspection, paid for by a fee of $27.24 per unit per year, covers compliance with codes for fire and life safety, building, electrical, plumbing, heat and ventilation, health, and lead hazards.

# Other resources utilized: N/A
Factors essential to implementation: The essential components are a professional code enforcement agency, a good database and tracking system, effective outreach and education of property owners and contractors, and consistency of treatment.

# Limitations/problems encountered:
The program needs to factor in that owners want to/need to recoup investment, and ways to help contractors understand potential liability.
Magnitude of Impact/Potential Impact: Approximately 180,000 units are inspected each year. In a pilot program in one-third of the council districts, inspectors who have been trained in lead safety are citing landlords for visible lead hazards and requiring that all work in pre-1979 buildings that disturbs paint be performed using lead-safe work practices. City inspectors make referrals to the county lead program to document violations. They also refer buildings where children are at-risk to community organizations, which deploy staff to educate tenants to identify and complain of unsafe work practices and to have their children screened.

# Building Blocks for Primary Prevention: Protecting Children from Lead-Based Paint Hazards
Financing and Subsidies SECURE DEDICATED FUNDING FOR CODE ENFORCEMENT Potential for replication: Moderate. Cities and counties that have a housing code could adopt a systematic enforcement program using fees or appropriations dedicated to code enforcement. While many codes do not specifically cover deteriorated paint, there are generally other habitability standards that can be cited. Codes inspectors need to be retrained to look at habitability issues, not just building or structural conditions.

# Contact for Specific Information

# Secondary Actor(s): N/A
Staffing utilized: No information provided.

# Other resources utilized: N/A
Factors essential to implementation: Registration is the key to success. Once a property is registered, it is possible to contact the owner or the owner's representative. The owner knows the property will be inspected and that it must be maintained. Regular inspections are essential to maintaining properties in a safe condition.
Limitations/problems encountered: It is very difficult to keep up with the constant turnover in ownership of small apartments. The vast majority of properties subject to registration and inspection are three-unit properties. Small property owners are investing for appreciation, not long-term ownership and with little attention to maintenance.
Magnitude of Impact/Potential Impact: 150,000 to 180,000 units are inspected annually.

# Centers for Disease Control and Prevention--Lead Poisoning Prevention Branch
Building Blocks for Primary Prevention: Protecting Children from Lead-Based Paint Hazards Financing and Subsidies SECURE DEDICATED FUNDING FOR CODE ENFORCEMENT Potential for replication: Moderate. Other states and localities seeking to replicate New Jersey's approach would need to find a basis for widespread registration that reflect their individual needs and past history. New Jersey laws grew out of a need to regulate tenements in the early 1900s and have gradually evolved since then. Also, the State has a unique relationship with its municipalities that is not common in most states.

# Contact for Specific Information
Michael Motich Supervisory Code Administrator 609-633-6225 Other resource requirements: While the direct outcome of a disclosure law will be providing families with information they need to make informed housing choices, the reality is that many families living in high-risk housing do not have real housing options. Therefore, the indirect goal of the disclosure requirement is to motivate property owners to go beyond merely providing information about lead hazards and take steps to address them. Resources to assist landlords of low-income properties and owner-occupants, including free trainings in lead-safe work practices and grants and low-or no-interest loans, would help accomplish this goal.

# LEAD SAFETY AND HEALTHY HOMES STANDARDS ADOPT STATE AND LOCAL LEAD HAZARD DISCLOSURE LAWS CERTIFY LEAD SAMPLING TECHNICIANS ENSURE LEAD SAFETY IN LICENSED CHILD CARE PROGRAMS ESTABLISH A LEAD-SAFE HOUSING REGISTRY MAKE LEAD HAZARDS A VIOLATION OF THE HOUSING OR HEALTH CODE NOTIFY ALL RESIDENTS IN A BUILDING FOUND TO CONTAIN LEAD HAZARDS PROTECT OCCUPANTS DURING HAZARD REMEDIATION AND RENOVATION WORK REQUIRE RENTAL PROPERTY OWNERS TO INFORM TENANTS HOW TO REPORT DETERIORATING PAINT REQUIRE SAFE WORK PRACTICES DURING REMODELING, REPAIR, AND PAINTING TRAIN PAINTERS, REMODELERS, AND MAINTENANCE STAFF IN LEAD-SAFE WORK PRACTICES

# Institutional capacity required:
The lead agency, presumably the health or housing department, must have the capacity to enforce the law in order for this strategy to make a meaningful difference. In addition, judges and prosecutors must be educated about lead poisoning and the goals of the law so that settlements and judgments go beyond collecting fines and actually require owners to take measure that will protect tenants.
Cost considerations: This is a low-cost way to motivate owners to invest in lead hazard control. The cost of enforcement can be offset by fees and fines.

# Timing issues:
The timeline to enact and initially implement a disclosure requirement can be quite long (18 months to 2 years or more), depending on the political climate and the calendar of the city council or state legislature.
Feasibility of Implementation: High, though the successful implementation of this strategy is dependent on legislative approval, which is difficult to predict. Building the support of community-based organizations, tenants, and others concerned about lead poisoning, such as pediatricians, will help achieve passage.

# POTENTIAL OBSTACLES/BARRIERS
Landlords, property management companies, and real estate agents may oppose this legislation. In addition, other agencies that need to be involved, such as inspection, code, building, and judicial agencies, may be resistant to taking on what they view as new responsibilities. Staffing utilized: It is estimated that approximately 1 FTE was needed over 12-18 months to conduct background research on other state and local lead laws; draft the legislation; build political support for the new law (including meetings with the Mayor and housing officials); and see it through the legislative process. The director of the CLPPP and a lawyer in the Law Department were the two primary staff who worked on the legislation. The staffing pattern to implement this local disclosure law has not been determined.

# Other resources utilized:
The program conducted research to review other state and local lead poisoning prevention laws and to survey HUD grantees to learn how they handle properties. The program used the Wisconsin law as a model.

# Factors essential to implementation:
Political support for the law was essential to its passage. In this case, the Mayor's support of the ordinance assured the support of the Housing Director and Housing Commissioner, both of whom are effective and influential.

# Limitations/challenges/problems encountered:
The actual implementation and enforcement of the law will depend on having adequate resources and effective communication and coordination between the health and housing departments.
Magnitude of Impact/Potential Impact: There are 178,000 homes in Cleveland built before 1978 that will be affected by the disclosure law. Of those, it is estimated that 120,000 (60%) contain lead hazards and would be candidates for enforcement.

# Contacts for Specific Information

# CRITICAL ELEMENTS
Staff requirements: States that already have EPA-authorized certification programs in place for lead abatement workers and supervisors, risk assessors, lead inspectors, and project designers will be able to add approval of certifications for LSTs with a nominal amount of staffing.

# Other resource requirements:
Training materials, testing material samples for practice in lead sampling.

# Institutional capacity required:
In some states, the laws establishing EPA-authorized certification programs may need to be amended to accommodate LST certification. Elsewhere, agencies administering EPA-authorized programs will only need to promulgate regulations detailing LST certification requirements. Accredited training providers may need to develop LST training programs, but states should be able to approve their plan to use the EPA model course.
Cost considerations: Once a LST certification program is underway, the increased availability of lead dust testing will bring the cost of that service down significantly.

# Timing issues:
Assuming the statutory authority to certify LSTs is in place, as much as a year may be required to adopt regulations. Individuals typically are certified as LSTs for one or two years and can easily extend their certification through renewal.

# Feasibility of Implementation:
High. Certifying LSTs as a free-standing discipline is readily achievable in states with EPA-authorized certification programs. In states not currently authorized by EPA to administer certification, sampling technicians who are certified by other states can perform non-abatement clearance in accordance with HUD regulations.

# POTENTIAL OBSTACLES/BARRIERS
Confusion or perceived competitive interests may interfere in consideration of certifying LSTs. The benefits of diversifying and expanding capacity need to be communicated.

# ADDITIONAL RESOURCES N/A

# ILLUSTRATION OF STRATEGY IN PRACTICE
In 2001, the State of Vermont promulgated regulations that permit the licensing of lead sampling technicians, completing a process that took roughly one year. Candidates are required to attend a five-hour training course designed to give them hands-on experience in conducting visual assessments and taking dust wipe samples, as well as sample submission, lab results interpretation, and other skills. To obtain a license, candidates must pass an exam at the end of the course. Lead sampling technician licenses must be renewed annually. For technicians working for private firms, the license fee is $150 per year; however, public employees and employees of non profit organizations that are not working commercially can have the fee waived. Licenses or certifications obtained in other states can also be used in Vermont. Lead sampling technicians in Vermont are allowed to perform a well-defined set of duties-they can conduct clearance testing following interim controls, renovations, remodeling, and ongoing maintenance. Sampling technicians cannot perform clearance testing after an abatement project or conduct random dust wipe sampling in multifamily properties.

# Jurisdiction or Target Area: Vermont

# ENSURE LEAD SAFETY IN LICENSED CHILD CARE PROGRAMS DESCRIPTION OF THE STRATEGY
Protecting children in child care settings is an essential complement to preventing exposure in the home environment. Requiring property owners of child care programs to certify annually that the program used essential maintenance practices during the previous year will prevent the occurrence of lead hazards. This certification is required for issuance or renewal of the program's child care license and must be filed with the program's insurance carrier.

# BENEFITS
Immediate/Direct Results: Once implemented, the program should result in direct and substantial reductions in lead hazards and deteriorated paint at child care programs covered by the regulations. Public Health Benefits: If a child care facility has lead hazards, children served by the program are likely to become lead poisoned. In addition, since these children may not be considered at high-risk for lead poisoning, they may not be identified under the targeted screening programs used in many states. Reducing lead hazards in child care programs will benefit all of the children who use the program's services.
Other Indirect/Collateral Benefits: The program should raise awareness of lead hazards for the families that use the child care program as the program cleans up problems or proudly declares that it has any potential problems under control.

# SCOPE OF POTENTIAL IMPACT
There are 100,000 licensed child care programs nationally serving children under six years old. According to the First National Environmental Health Survey of Child Care Programs, 14 percent of licensed child care programs in the United States have significant lead-based paint hazards -primarily deteriorated lead-based paint. 470,000 children attend these programs. For programs in buildings built before 1960, the rate is 26 percent. For programs where the majority of the children are African American, the rate is 30 percent.

# CRITICAL ELEMENTS
Staff requirements: The program will take at least one year to develop, including adoption of laws or rules, development of coalitions, and production of outreach materials. It will take approximately 0.2 FTE to prepare the program, educate child care providers, and manage the program for the first two to three years. In addition, inspectors normally conducting the program inspections will need to be trained to address the issue and integrate compliance monitoring for lead into their workload. The additional inspection burden should be minimal-about 15 minutes per site visit.
Other resource requirements: It may help improve compliance if some inspectors are trained and certified or licensed to conduct a clearance examination. If inspectors will be expected to take dust wipe samples, they will need about $50 per facility for lab analysis of samples. While not essential, statutory authority such as Vermont's will make it easier. The programs will also need access to contractors and maintenance workers trained in lead-safe work practices to ensure that essential maintenance practices for lead safety are properly done. Some inspection staff may need to be qualified as lead sampling technicians to enhance compliance.

# Centers for

# Cost considerations:
Child care programs often operate on a tight budget. Many programs lack the resources to remedy lead hazards. Unless resources are provided, programs may be confronted with closure. The programs most at risk for lead hazards are the ones most likely to need the resources.
Timing issues: It will take approximately one year to establish the program and build support for it. Full implementation will usually take two more years. Child care programs are busiest-and therefore unavailableduring August and September when children return to school and enrollment adjusts to the changes.

# Feasibility of Implementation:
Moderate. The program is feasible to implement in jurisdictions with lead hazard control resources to devote to child card facilities, but it will take the support of agency and political leadership since additional requirements will be imposed on child care programs.

# POTENTIAL OBSTACLES/BARRIERS
Management support is essential to overcoming concerns by programs and to manage staff reluctance to expand their inspection role and respond to program concerns. Communities need to be prepared to identify potential resources to address lead hazards and provide technical assistance to help programs obtain and use those resources.

# ADDITIONAL RESOURCES

# ILLUSTRATION OF STRATEGY IN PRACTICE
In 1996, Vermont adopted a law requiring all licensed child care programs, including those operated as "Family Day Care Homes," to perform annual Essential Maintenance Practices (EMPs). The programs certify that they have completed essential maintenance practices to reduce lead hazards during the previous year.

# POTENTIAL OBSTACLES/BARRIERS
Some resistance from landlords and realtors may occur, in objection to the use of public resources to the benefit of owners of lead-safe properties and to the disadvantage of property owners not on the list (or who will have to undergo costly renovations and repairs to qualify). However, public health concerns should outweigh these arguments. Other resources utilized: HUD Lead Hazard Control funds were used for registry start-up.

# ADDITIONAL RESOURCES
Factors essential to implementation: Factors essential to implementation of the lead-safe housing registry in Montgomery County included the availability of HUD grant funds and the cooperation of the cities of Kettering and Dayton, as well as assistance from a variety of other parties, including the Sunrise Center, the CityWide Development Corporation, and the Center for Healthy Communities.
Limitations/challenges/problems encountered: There were no significant limitations or challenges encountered in establishing the Montgomery County Lead-Safe Housing Registry.
Magnitude of Impact/Potential Impact: The Montgomery County registry currently lists 102 owneroccupied housing units and 56 rental units as lead-safe.

# Potential for replication:
Cities and counties that receive state or federal grant funds can easily establish a leadsafe housing registry as part of their overall programs. Eleven counties in California and the City of Long Beach have established similar registries.

# ILLUSTRATION #2 OF STRATEGY IN PRACTICE
The Lead Safe Housing Registry in Maryland is a product of the Coalition to End Childhood Lead Poisoning, a nonprofit organization headquartered in Baltimore. The registry is a statewide list of currently available rental properties that, according to the records of the Maryland Department of the Environment, are in compliance with state and federal lead safety standards. Properties on the registry are designated as having undergone a full risk reduction or as being lead-safe or lead-free. The list is unique in that it shows only properties currently available for rent, along with the type of unit (apartment, townhouse, etc.), some of the amenities, the amount of the security deposit, the total rent per month, and whether the unit is eligible for subsidy under HUD's Section 8 Housing Choice Voucher program. In addition, some of the properties listed on the housing registry are considered affordable housing.

# Jurisdiction or Target Area: Maryland

# Primary Actor: Coalition to End Childhood Lead Poisoning
Secondary Actors: N/A Staffing utilized: The Coalition did a lot of preliminary groundwork in establishing Maryland's lead-safe housing registry. 1-2 FTE were temporarily needed for this process. Maintaining and updating the list on a biweekly basis requires 0.25 FTE.

# Other resources utilized: N/A
Factors essential to implementation: The initial and ongoing cooperation of the state of Maryland has been essential to the Coalition in implementing this strategy.

# Limitations/challenges/problems encountered:
The Coalition has encountered several challenges in making its registry as complete as possible. The State of Maryland is prohibited by law from making public an inventory of properties owned by a specific landlord or leasing company for any purpose, so the Coalition must list units on an individual basis. Also, although the Coalition attempts to provide a large selection of lead-safe affordable housing, these properties are in short supply. Developing the housing registry for the less urban sections of Maryland (i.e. outside the Baltimore metro area and the Washington, DC suburbs) is another challenge for the Coalition.
Magnitude of Impact/Potential Impact: The impact of this registry is statewide. Properties from every county can be included on the registry. Because the registry can include a limitless number of affordable housing units, it can have positive impacts on low-income families in Maryland.

# ILLUSTRATION #3 OF STRATEGY IN PRACTICE
The Wisconsin Lead-Free/Lead-Safe Registry is a listing of houses, apartments, day care facilities, and other buildings that meet the state's lead-free or lead-safe property standard. The lead-free standard is met when a property does not contain lead-based paint. A lead-safe property is one that does not contain lead hazards, such as peeling, chipping, or flaking lead-based paint.
A property owner may apply to be added to the registry by obtaining a lead-free or lead-safe certificate, which is issued following an inspection by a certified lead inspector or risk assessor. Lead-safe certificates are valid for a set period of time as determined by DHFS; lead-free certificates do not expire.
The Lead-Free/Lead-Safe Registry is posted online; the .pdf file is updated whenever a significant number of properties have been added. The registry is organized by county and lists the address of the property, whether the property is lead-free or lead-safe, and contact information for the property owner or the owner's representative. DHFS is working to make the information available in an interactive format through the Wisconsin Asbestos Lead Database Online (WALDO). While no definite timeline has been set, ultimately the database will be located at /.

# Jurisdiction or Target

# Other resources utilized: N/A
Factors essential to implementation: The policy requiring DFHS access to addresses of lead-safe/lead-free properties and the availability of these addresses to the public has been crucial to the success and timeliness of the registry.
Limitations/challenges/problems encountered: Publishing the WALDO database online has been the main challenge for DHFS. While an online version currently exists to collect input from property owners, it is complicated and too cumbersome for display and interactive activity by website visitors. DHFS is currently seeking funding to make the database more user-friendly and fully available to the public.

# Building Blocks for Primary Prevention: Protecting Children from Lead-Based Paint Hazards
Lead Safety and Healthy Homes Standards

# MAKE LEAD HAZARDS A VIOLATION OF THE HOUSING OR HEALTH CODE DESCRIPTION OF THE STRATEGY
In order to provide the clearest legal basis for code officials to confront lead hazards, local and state codes should state explicitly that deteriorated lead-based paint and dangerous levels of lead in dust and bare soil constitute violations of the housing or health code. Specifically referencing lead hazards in the housing or health code will alert enforcement officials and property owners alike that such hazards constitute code violations and must be corrected. The code can explicitly incorporate EPA's national standard for dangerous levels of lead in paint, dust, and soil that state and local jurisdictions can reference.

# BENEFITS
Immediate/Direct Results: Enforcement officials have the authority to mandate repair or abatement and cite property owners who fail to comply. Public Health Benefits: Children are protected from exposure because hazards are addressed on a pre-emptive basis.
Other Indirect/Collateral Benefits: With the prospect of enforcement and fines, some property owners may be motivated to repair their property before problems occur.

# SCOPE OF POTENTIAL IMPACT

# CRITICAL ELEMENTS
Staff requirements: Since adding lead hazards supplements existing code enforcement programs' authority, no additional staffing would be needed.

# Other resource requirements: N/A
Institutional capacity required: The initial requirement is local or state legislation that names deteriorated lead-based paint and dangerous levels of lead in dust and bare soil as code violations. Implementation requires training for code staff in the identification of lead hazards and certification to become lead sampling technicians, lead-based paint inspectors, or risk assessors.
Cost considerations: None identified.

# Time issues: None
Feasibility of Implementation: High. Adding lead hazards to the housing code is not difficult to implement.

# POTENTIAL OBSTACLES/BARRIERS
The strategy has limited usefulness if local jurisdictions do not have the budget or staff to investigate and enforce violations.

# ADDITIONAL RESOURCES

# ILLUSTRATION OF STRATEGY IN PRACTICE
The Town of Manchester's Property Maintenance Code requires that interior and exterior lead-based paint must either be maintained in a condition free from peeling, chipping, and flaking or be removed or covered in an appropriate manner. Cases involving lead-based paint violations are referred to the health and building departments to pursue compliance with state and federal regulations. If a child under six years of age resides in a property with deteriorated, flaking, or loose paint conditions, dust wipe samples are collected. If lab analysis results reveal lead hazards, repairs are ordered and the property owner is referred to the Lead Abatement Project, which may provide financial support to complete the repairs. Participants in the program are required to obtain lead safe work practices training.

# Jurisdiction or Target Area: Manchester, CT
Primary Actor: Department of Health, Lead Abatement Project, in conjunction with the city's Code Enforcement Unit.

# Secondary Actor(s): N/A
Staffing utilized: Only 0.2 FTE is available to address Property Maintenance Code complaints. One full time Property Maintenance Inspector, with support staff, would be needed to proactively address lead hazards in a town the size of Manchester.

# Other resources utilized: N/A
Factors essential to implementation: Strong partnership with a childhood lead poisoning prevention program and enough staff to implement property maintenance code.
Limitations/challenges/problems encountered: Generally, Code Department personnel focus primarily on new construction and only react to property maintenance complaints, so there is a need for on-going education and advocacy about lead hazards in older properties. Nonetheless, a partnership between the building inspectors and the Lead Abatement Project has made a difference.
Magnitude of Impact/Potential Impact: By making lead hazards part of the Property Maintenance Code, Manchester has institutionalized the importance of recognizing and addressing them. This is an essential step in eradicating lead poisoning, particularly in an area where 93 percent of the housing is at risk for lead hazards.

# Potential for replication:
High. The housing code provision is not difficult to implement, but to reach its full potential impact, the jurisdiction should have sufficient resources for code inspection and enforcement.

# Contacts for Specific Information

# NOTIFY ALL RESIDENTS IN A BUILDING FOUND TO CONTAIN LEAD HAZARDS DESCRIPTION OF THE STRATEGY
The presence of lead hazards in one unit of a multi-family building is a strong indication that other units in the building also contain hazards. Through statutes or code, hazard assessment staff can be given the authority to notify, or rental property owners can be required to notify, all building residents of any evaluation, inspection, other hazard determination, hazard reduction activities, or clearance testing performed in the building. By putting all occupants on notice when hazards are identified, residents can take steps to protect their children from lead poisoning.

# BENEFITS
Immediate/Direct Results: Occupants will become aware of existing lead hazards and may be motivated to seek an assessment or corrective action in their own unit. As a result, other hazards in the same building will be identified and remediated before more children are poisoned. Public Health Benefits: Expand awareness and education of lead hazards among residents.
Other Indirect/Collateral Benefits: Notification of all tenants provides an opportunity for community building among residents.

# SCOPE OF POTENTIAL IMPACT
Statewide City-or County-Wide

# PRIMARY ACTORS
Code or Housing Inspection Agency

# KEY PARTNERS

# Tenants

# CRITICAL ELEMENTS
Staff requirements: Approximately 0.05 FTE.

# Other resource requirements: N/A
Institutional capacity required: Hazard assessment personnel must have the authority to notify all residents when a unit located in the same structure is cited for lead hazards.

# Cost considerations: None listed

# Timing issues: None
Feasibility of Implementation: Very high. This is a simple, low-cost education and outreach tool.

# POTENTIAL OBSTACLES/BARRIERS
Non-English-speaking tenants need notice and educational materials in the appropriate language. to notify all residents of a building where an investigation documents lead hazards in any unit in that building. When an inspection reveals lead hazards, the environmental health inspector gives the property owner a report highlighting the hazard and where it is located and instructs the property owner to copy and distribute the notice to all tenants in the building. In order to ensure all tenants actually receive the notice, the department also distributes copies, along with lead hazard educational materials. The materials are available in Chinese, Spanish, and English.

# ADDITIONAL RESOURCES

# Jurisdiction or Target

# Secondary Actor(s): N/A
Staffing utilized: 0.05 FTE to prepare the photocopies, assemble the literature, and distribute it to tenants.
Other resources utilized: A photocopier and educational literature.

# Factors essential to implementation:
The Health Code gives inspectors the authority to notify all tenants.
Limitations/challenges/problems encountered: The challenge involves distributing the flyers and ensuring that materials are provided in the appropriate language for the tenants.

# Magnitude of Impact/Potential Impact: The Children's Environmental Health Promotion Program
has not yet collected data on this strategy's impact, but inspectors consider it a strategy complementary to their overall environmental health promotion. Distributing notice to all tenants is another way to build awareness and reinforces the seriousness of San Francisco's lead problem.
Potential for replication: Very high. This strategy is easily replicated with very little cost incurred.

# Contact for Specific Information

# PROTECT OCCUPANTS DURING HAZARD REMEDIATION AND RENOVATION WORK DESCRIPTION OF THE STRATEGY
Generally, occupants of homes that contain lead-based paint should be temporarily relocated to lead-safe housing before the start of lead hazard control work, or renovation or remodeling work that disturbs more than a small area of lead-based paint, and they should not return until the work is completed and the work site has been vacuum cleaned and wet washed and passed clearance.
Relocation is not necessary if work area containment is practiced and either only a few square feet of paint will be disturbed or the work can be completed in a few days while occupants stay out of the work area.
Temporary relocation can be carried out most efficiently and costs minimized by (a) ensuring that paintdisturbing work is completed as quickly as possible; (b) occupants are fully advised in writing of the necessity of not returning until the dwelling has been thoroughly cleaned; and (c) arrangements are made in advance for the protection and security of occupants' belongings and for the transportation needs of schoolchildren.

# Building Blocks for Primary Prevention: Protecting Children from Lead-Based Paint Hazards
Lead Safety and Healthy Homes Standards PROTECT OCCUPANTS DURING HAZARD REMEDIATION AND RENOVATION WORK incidental costs. Where private sector accommodations must be used, relocation costs can be minimized if the agency can establish a public-private partnership with hotels or motels to set aside low-cost rooms for temporary relocation.
In addition, it is conceivable that a temporary relocation requirement will result in rental property owners passing the cost to tenants in the form of higher rent.

# Timing issues: N/A
Feasibility of Implementation: High. Encouraging temporary relocation to homes of the occupant's friends or relatives may be one practical way of minimizing costs and ensuring successful implementation. Otherwise, feasibility will depend upon the availability of funds to implement a program.

# POTENTIAL OBSTACLES/BARRIERS
It may be very difficult to impose temporary relocation requirements on landlords without the availability of some type of cost-sharing.

# ADDITIONAL RESOURCES N/A

# ILLUSTRATION OF STRATEGY IN PRACTICE
This strategy is HUD's temporary relocation policy for federally assisted housing rehabilitation and renovation work. The policy provides for temporary relocation of residents to lead-safe housing during the work period, but it does not require relocation if certain requirements are met. If only a small area of paint will be disturbed; if the work can be completed in one 8-hour work day or within five calendar days, occupants are kept out of the work area, warning signs are placed in each room where work is occurring, and the area is thoroughly cleaned are work is completed; or only outside work is involved, the property owner does not have to relocate the unit's occupants. Other resources utilized: Some agencies allow temporary relocation costs as an eligible expense for housing rehab programs.

# Jurisdiction or Target
Factors essential to implementation: Coordination and cooperation among occupants, property owners, and contractors involved in the rehabilitation and renovation work. It also requires ongoing inspection and enforcement by HUD and local housing agencies.
Limitations/challenges/problems encountered: HUD exempted elderly homeowners from relocation requirements since local agencies reported that this population did not want to be relocated and was considered at low risk. Other resource requirements: Additional staff dedicated to ensuring landlord compliance probably could be funded mostly or entirely from penalties assessed against non-complying landlords.

# Magnitude of Impact
Institutional capacity required: State or local legislation would need to be enacted to create the notice requirement and enforcement authority to ensure compliance.
Cost considerations: This requirement seems cost-effective no matter how passively or aggressively it is enforced. Without enforcement, some compliance will occur at virtually no cost. Additional resources spent on landlord outreach and education and/or enforcement should increase compliance substantially. Penalties against non-compliant landlords would increase in proportion to resources spent on enforcement and cover or at least offset costs of enforcement.

# Timing issues:
No seasonal or cyclical considerations. Timeline to implement depends on the legislative process.

# Feasibility of Implementation:
Moderate. The existence of this policy in two states and throughout most federally assisted housing demonstrates its feasibility.

# POTENTIAL OBSTACLES/BARRIERS
The impact of this policy is directly related to the degree to which it is promoted and enforced among landlords. Some resources would have to be committed initially in order to demonstrate cost effectiveness of promotion and enforcement. This is most likely to happen if policy makers are shown or convinced that enforcement efforts can pay for themselves.

# ADDITIONAL RESOURCES N/A

# ILLUSTRATION OF STRATEGY IN PRACTICE
In 1996, the Vermont Legislature enacted the Essential Maintenance Practices law, which includes a requirement that owners of pre-1978 rental housing and child care facilities "post, in a prominent place ... a notice to occupants emphasizing the importance of promptly reporting deteriorated paint to the owner or to the owner's agent. The notice shall include the name, address, and telephone number of the owner or the owner's agent." The law also requires owners of pre-1978 rental housing to annually submit an Affidavit of Performance attesting to compliance with this and the other requirements to the Vermont Department of Health. Limitations/challenges/problems encountered: Although VDH is charged with implementing the law and keeping records, no money is appropriated for these activities or for enforcement. VDH does not have the resources to conduct quality control on affidavits to verify they are correctly completed or to physically check dwellings to confirm compliance. Currently, VDH attempts to resolve complaints informally but does not use its statutory power to penalize non-compliant landlords. VDH has never issued a health order to address violations of the law-even after the infraction caused a child to be lead poisoned. Failure to prosecute even the most egregious cases means there are essentially no negative consequences to ignoring the law.

# Jurisdiction or Target
Magnitude of Impact/Potential Impact: Approximately 30-40 percent of Vermont's pre-1978 rental housing units have affidavits on file at VDH that claim compliance. According to officials, the lack of any comprehensive listing of rental properties hinders the agency's ability to get a precise picture of compliance. However, Vermont is poised to have a larger impact in the future, and other jurisdictions with more staff availability could be even more effective.

# REQUIRE SAFE WORK PRACTICES DURING REMODELING, REPAIR, AND PAINTING DESCRIPTION OF THE STRATEGY
Banning unsafe work practices and requiring basic safeguards for remodeling and paint repair work are key to preventing childhood lead poisoning in older housing. Banning unsafe methods of removing paint will sharply reduce the amount of lead contaminated dust that would otherwise be generated. The unsafe methods that should be prohibited include: dry sanding or scraping; open flame burning; operating a heat gun above 1100 degrees; machine sanding without a HEPA attachment; and stripping in poorly ventilated areas using volatile strippers on surfaces containing lead-based paint. Requiring precautions such as work area containment and careful post-work cleaning will prevent the dispersal of any lead-contaminated dust that might be generated. When coupled with occupant protection activities, adherence to lead-safe work practices for routine remodeling and repair work can help prevent children's exposure to lead dust hazards.

# BENEFITS
Immediate/Direct Results: Homes that are being remodeled, repaired, or repainted are less likely to pose lead dust hazards if contractors refrain from unsafe work methods that generate lead dust and follow basic precautions while performing work that disturbs paint in older homes. Public Health Benefits: Following lead-safe work practices will materially reduce risks to children living in older homes that are undergoing repairs or renovation. In many areas, such as New England, up to 20% of lead poisoning cases can be attributed to unsafe remodeling or renovation activities. Other Indirect/Collateral Benefits: A requirement for using lead-safe work practices would also reduce exposure of workers, and potentially their children, to dangerous levels of lead dust.

# SCOPE OF POTENTIAL IMPACT
A requirement for using lead-safe work practices could be implemented statewide or at the county or city level. Similar requirements already apply to all remodeling, rehab, and paint repair projects in HUD-assisted housing and properties rehabilitated using HUD funds. Cost Considerations: Because some banned work practices, such as machine sanding, reduce labor time in surface preparation, painting contractors and their clients would bear marginal increased costs. Timing Issues: Developing and implementing systems to train remodeling contractors, painters, and maintenance workers will take time.

# PRIMARY ACTORS KEY PARTNERS
Feasibility of Implementation: Moderate. Training to build lead safety capacity can start before requirements are in place. Health department leadership will accelerate acceptance and enactment of lead-safe work practices requirements. Substantial support from community and advocacy organizations will help. Property owner and contractor associations should be asked to participate in developing the statute, ordinance, or code amendment to offset their likely opposition. Compliance will grow over time, because most contractors are law-abiding or interested in avoiding legal liability and are responsive to consumer awareness and demand for lead safety. Success is more likely in areas with a relatively high incidence of lead poisoning and broad public awareness.

# POTENTIAL OBSTACLES/BARRIERS
The main obstacles are likely to be the opposition of property owners and contractors to enactment of requirements for lead-safe work practices.

# ADDITIONAL RESOURCES N/A

# ILLUSTRATION OF STRATEGY IN PRACTICE
In 2001, the City of New Orleans enacted an ordinance that prohibits unsafe work practices during work on metal structures and buildings built before 1978. It requires that contaminated debris be contained within barriers and that visible paint chips be cleaned after completion of work. It also requires that tenants, neighbors, workers, and government agencies be notified that work on interior and exterior painted surfaces will take place and forbids retaliatory evictions. Enforcement is mostly by complaint and is more effective for work on exteriors that are evident to neighbors. The city is authorized to issue notices of violation, to require remediation of any lead-based paint hazards generated by unsafe work, and to require a risk assessment before resumption of work. Factors Essential to Implementation: A coalition of physicians and community advocates worked with the city's administration to develop the ordinance, which was passed in the wake of a survey finding that 25 percent of children screened at city-operated clinics had elevated blood lead levels. City departments and advocates must ensure wide publicity and education so that tenants and neighbors will report violations and so that violations will be vigorously pursued.

# Jurisdiction or Target

# Limitations/challenges/problems encountered:
The ordinance only applies to lead-based paint, which allows painters and owners to submit an unleaded paint chip to circumvent all requirements.

# Building Blocks for Primary Prevention: Protecting Children from Lead-Based Paint Hazards
Targeting High-Risk Housing

# CAPITALIZE ON HOME NURSING VISITS TO TARGET PREVENTION SERVICES DESCRIPTION OF THE STRATEGY
Visiting nurse programs offer a unique opportunity to efficiently reach pregnant women and new mothers in high-risk communities. Traditional home nursing visits can be enhanced to visually assess hazards, collect dust samples, inform occupants and rental property owners of hazards, demonstrate specialized cleaning methods for lead dust, and discuss lead poisoning risks. Further, and most critically, the nurses can provide referrals to available lead hazard control resources and other resources.

# BENEFITS
Immediate/Direct Results: Education and referrals provided during home nursing visits directly benefit the families served. The physical presence of nurses in the homes provides a mechanism for nurses to identify conditions that may warrant emergency interventions, even outside the context of formal policies for such action.
Public Health Benefits: Lead safety improvements triggered by nurse visits benefit siblings and future occupants. In addition, home nurse visits provide a mechanism for targeting available lead hazard assessment and/or control services to high-risk families who can benefit immediately. Over time, cumulative efforts will help improve the lead safety of the housing stock.
Other Indirect/Collateral Benefits: Word-of-mouth among new mothers may reinforce efforts to raise awareness among families in the community. Nurse referrals may help generate referrals to other community programs, such as weatherization or lead hazard control, thereby reducing marketing efforts for such programs.

# SCOPE OF POTENTIAL IMPACT
City-or County-Wide

# PRIMARY ACTORS KEY PARTNERS
Health Department

# CRITICAL ELEMENTS
Staff requirements: Staffing needs depend upon whether the lead activities are provided as an adjunct to home nurse visits that are already being made, or whether they are an entirely new service, and by the scope of services provided.
Other resource requirements: If nurses will be collecting dust samples or demonstrating lead-safe cleaning techniques, they will need the appropriate tools (such as wipes for dust sampling, HEPA vacuum, etc.) and protocols, along with any necessary training.
Institutional capacity required: Management support is the most likely element required for continued support of a staff-intensive effort.

# Cost considerations:
To maintain the visiting nurse program's existing coverage of its target population caseload, the incremental cost of adding lead safety to the visiting nurse protocol will need to be reimbursed so that the staff can be expanded accordingly.
Timing issues: Can be implemented at any time.

# Feasibility of Implementation:
High. As demonstrated by the adoption of this strategy in multiple jurisdictions, the strategy is feasible in multiple variations. If programs seek to add lead hazard education to previously planned nursing visits, they may run the risk of overwhelming both parents and the nurses by providing too much information at one time, ultimately making the sessions less effective.
Nurses and families may be frustrated by the lack of meaningful lead hazard control resources available in the community. Pregnant women may resist interventions that could lead to uncomfortable relationships with landlords or even evictions; the program should develop a contingency strategy for landlord retaliation (with assistance from a legal aid agency and/or the code enforcement agency) and explain it to their patients.

# ADDITIONAL RESOURCES N/A

# ILLUSTRATION #1 OF STRATEGY IN PRACTICE
With the support of a CDC $100,000 primary prevention grant, WI CLPPP developed and pilot-tested a nursing home visitation program in two high-risk Wisconsin communities (Racine and Sheboygan). Although the one time CDC grant has ended, the program since has evolved into a different but sustainable format, with 34 programs run by local health departments throughout the state.
The initial pilot program, which targeted low-income, primarily Medicaid-eligible, pregnant women through the Prenatal Care Coordination Program (PNCC), provided prenatal lead education and referrals, environmental assessments, and feedback to property owners. Fourteen PNCC nurses were trained as Lead Sampling Technicians and equipped with HEPA Vacuums. During initial prenatal home visits, a nurse provided information about childhood lead poisoning and potential lead hazards in the home environment. The nurse also conducted a visual assessment of the home, collected pre-and post-cleaning lead dust samples from floors and windows, demonstrated lead dust reduction measures, and provided cleaning supplies to the parent. During a second visit four-six weeks later, nurses reinforced messages and collected lead dust samples from the same locations to assess the effectiveness of measures that were taken to reduce lead dust. Pre-and post-cleaning results were provided to clients. Finally, property owners were informed in writing of the results of the dust sampling, given a copy of the HUD Lead-Paint Safety Field Guide, and encouraged to repair deteriorated painted surfaces. Families and property owners were also encouraged to enroll their properties in the HUD Lead Hazard Reduction Program if appropriate.
After CDC funding ended, Wisconsin revised the program to reach a broader target audience by adding an additional lead-specific home visit to existing prenatal and newborn visitation programs. Local health departments (LHD) now choose the level of intensity of services provided during their lead visits, selecting various combinations of three options: lead education, environmental assessments, and feedback to property owners. Due to capacity and resource constraints, not all LHDs are doing dust sampling; some are using LeadCheck swabs. The state is continuing to support local efforts, currently devoting about 15 percent of two FTEs to support the program and budgeting about $35,000 per year. Local LHDs estimate their costs at about $3,000 per year. To help build capacity and support dust sampling, Wisconsin is training an additional 23 nurses as lead sampling technicians and plans to offer free dust sample analysis through the state lab.

# Jurisdiction or Target Area: Wisconsin

# Other resources utilized: N/A
Factors essential to implementation: The willingness of visiting nurse program to train nurses as LSTs, and lab resources for dust wipe analysis, were essential to implementing this strategy.
Limitations/challenges/problems encountered: Initial concerns about creating conflict by contacting property owners proved to be mostly unfounded. In fact, the program has been so popular that nurses in one locality fought successfully to protect it from threatened budget cuts.
Magnitude of Impact/Potential Impact: During the nine-month pilot, approximately 100 families received services. WI CLPPP estimates that some level of service has been provided to about 500 families statewide this year, and expects the number to reach 1,200 by the end of year. The program has been well received statewide by nurses and families.
Potential for replication: High. Widely replicable in jurisdictions with visiting nurse programs. Through partnership with the Weatherization program, the KYBLS project aims to literally get a "foot in the door" by delivering an energy-efficient, lead-safe environment at no cost and with minimal involvement of the property owner. Weatherization program policies do not require the permission of the property owner to perform an initial energy assessment. The property owner's signature is only needed in order to perform energy conservation treatments (which involve no cost to the property owner and no threat of legal penalty). CLPPP sought to utilize these facets of the Weatherization Program to initiate contact with property owners offering an opportunity to improve their properties for free, easing the concerns of women who feared conflict with or eviction by their landlord, and following up with contact regarding the need to repair lead hazards.

# Contacts for Specific Information
Following the birth of each participant's child, the program uses RI health department (KIDSNET) and CLPPP databases to identify and track the child up to the first blood lead level screen, to serve as another method of evaluation method for the project. The educational impacts of the KYBLS project continue to be assessed through an analysis of both the pre-and post-educational surveys administered to participants at the initial and final stages of their enrollment, as well as the pre-and post-dust wipe samples taken by the FOP workers at the homes of KYBLS enrollees. RI CLPPP has budgeted $100,000 per year for KYBLS.

# Jurisdiction or Target

# Other resources utilized: N/A
Factors essential to implementation: The essential factor is the cooperation between the health department and the weatherization agency.
Limitations/challenges/problems encountered: Unfortunately, implementation has proven to be very challenging, since a waiting list for weatherization services delays access to the property improvements to be provided at no cost, and property owners are not very enthusiastic about financing lead hazard controls via the loans that are offered. Many of the referred women refused services, could not be located, or did not meet eligibility requirements. Because the program began as a small pilot program, to date only a handful of properties have been successfully enrolled into lead hazard control or weatherization programs.

# Magnitude of Impact

# CONNECT MEDICAID DATA AND STATEWIDE SURVEILLANCE DATABASES DESCRIPTION OF THE STRATEGY
By linking the state's Medicaid data electronically with statewide lead poisoning surveillance databases, states determine testing rates for children served by Medicaid and identify children in the Medicaid caseload who have not been screened. Analysis of these data can also be used to identify and target neighborhoods in which numerous Medicaid children have been poisoned in order to direct prevention resources to areas at highest risk. Since 1998, CDC has been encouraging states to make these connections by requiring lead poisoning prevention grantees to have a system for ongoing identification of Medicaid-eligible children in the surveillance system, preferably via performing automated data linkages or matches between surveillance and Medicaid enrollment data sets.

# BENEFITS
Immediate/Direct Results: Data sharing improves the ability of the lead program and state Medicaid agency to systematically target prioritized primary prevention in high-risk neighborhoods. Public Health Benefits: Data sharing combines information sources and it sheds enormous light on "high risk" Medicaid populations, who can be targeted for primary prevention. Combining information sources also permits agencies to focus EBL screening efforts in neighborhoods where screening is required but not happening and better monitor both case-identification rates and the actual delivery of lead screening services, including the performance of individual Medicaid managed care plans and medical practices. It can also permit agencies to track follow-up care provided by local health departments and justify Medicaid reimbursement for such services. Other Indirect/Collateral Benefits: In addition to links between lead surveillance and Medicaid enrollment data, linkages can be established with other systems, such as geographic information system (GIS) coding and other programs' enrollment data. When illuminated by GIS, the matched data can yield clear and persuasive maps presenting risk, screening, or case-identification data for specific neighborhoods. The lead program can share analyses of the resultant combined data (suppressing identifying information) with housing agencies to facilitate targeting of resources for housing rehab and up-front lead hazard control to highest-risk blocks and block groups, or combine it with WIC enrollment data to discover risk relationships that can improve targeting strategies for primary or secondary prevention initiatives. Institutional capacity required: Information system managers for both agencies must understand the project goals and have top-down support for a joint project. Interagency agreements and even legislation supportive of sharing the data may be required.

# SCOPE OF POTENTIAL IMPACT

# Cost considerations:
Net costs depend on the status of the existing data systems. The cost of data matching is an allowable state administrative cost under Medicaid and therefore partially reimbursable by CMS.
Timing issues: Can be implemented whenever systems and support are in place.

# Feasibility of Implementation

# POTENTIAL OBSTACLES/BARRIERS
Poor quality underlying data is a prohibitive barrier to a successful data sharing project, as any data linkages are only as good as the information being compared. A common obstacle arises if the necessary data sets are housed in different agencies or in different locations, or split between agencies with poor working relationships. There is ample evidence that such obstacles can be overcome in any state, by enlisting senior management's early support for the project.
Privacy and confidentiality issues make all public agencies anxious about sharing data, and such concerns have been heightened by perceived new requirements associated with the Health Insurance Portability and Accountability Act's Standards for Privacy of Individually Identifiable Health Information (commonly known as the HIPAA Privacy Rule). It is imperative that proponents of data sharing be familiar with the facts about HIPAA as well as applicable state or local privacy policies. Some states have laws that require sharing of such data.

# ADDITIONAL RESOURCES
A number of resources are available to assist states in taking this step.

# ILLUSTRATION OF STRATEGY IN PRACTICE
The Chicago CLPPP regularly matches its lead surveillance database with Medicaid eligibility and billing data (two separate Medicaid databases) to track and analyze screening and EBL rates. Each quarter, CLPPP performs a data match and then translates the results into a standardized report for the Medicaid agency. The report contains aggregate information on the number of Medicaid-enrolled children tested by age, race, address, and other factors of interest, as well as information on blood lead levels by various criteria. It also includes a list of untested children, which is used for direct outreach by CLPPP to encourage testing. In addition, since the data are geo-coded by address, the CLPPP program uses the data to validate high-risk areas for HUD funds and other prevention efforts and to generate "good visuals" (i.e., mapped data) that help in mobilizing partnerships for prevention in problem areas.

# Jurisdiction or Target

# Other resources utilized: N/A
Factors essential to implementation: The city health department successfully negotiated its data-sharing agreement directly with the state Medicaid agency, the Illinois Department of Public Aid. Program staff believes that the key ingredient for a successful project is the existence of a clean blood lead surveillance database, which can be a challenge given that it is constructed by the CLPPP from information provided by providers who collected the samples and the laboratories that analyzed the samples. In contrast, Medicaid data tends to be relatively clean. Chicago modeled its approach after two states' successful efforts (NC and WI). Chicago CLPPP staff sought advice and technical assistance from peers in those states, who were gracious about sharing their data matching protocols.
Limitations/problems/challenges: Completing development of the agreement between the agencies was regarded as the biggest challenge to the program. respect to the identity of children in lead surveillance databases, and in some circumstances, address information.

# Cost considerations:
There are out-of-pocket costs associated with programming, acquiring data, cleaning databases (if necessary), and licensing software; however, specific costs will vary depending on a number of factors. Purchase of GIS software is now an authorized expenditure for CDC CLPP grant funds.
Timing issues: Can be implemented at any time.

# Feasibility of Implementation:
Moderate. A number of programs have already deployed GIS technology successfully to analyze data related to lead poisoning prevention, providing useful models and resources for support, advice, and practical tools.

# POTENTIAL OBSTACLES/BARRIERS
Although "mapping" feels approachable, the concept of Geographic Information Systems (GIS) can be intimidating for those unfamiliar with the software. Programs need to set clear goals for their analyses and decide if simple and focused will accomplish their goals (e.g., Wisconsin illustration), or if something more complex and comprehensive is appropriate (e.g., NCHH illustration).
A potential barrier that can require considerable staff time to remedy is the quality of the databases. Generally speaking, tax assessor databases are relatively clean, due to their importance to local government finances, while lead surveillance data tends to require cleaning to render it intelligible for GIS programs.
It is also possible that very small scale mapping (e.g., at the block level) of EBL data could trigger privacy concerns, so agencies must have clear policies in place in comply with prevailing privacy requirements.

# ADDITIONAL RESOURCES Building Blocks for Primary Prevention: Protecting Children from Lead-Based Paint Hazards
Targeting High-Risk Housing CONSOLIDATE AND ANALYZE DATA TO HIGHLIGHT LEAD POISONING "HOT SPOTS"

# ILLUSTRATION #1 OF STRATEGY IN PRACTICE
WI CLPPP used GIS software to produce maps demonstrating visually the association between childhood lead poisoning and age of housing. Specifically, Wisconsin developed a series of maps showing both the geographic location of residences of children with elevated blood lead levels (data from the state's blood lead surveillance system) and age of housing (data from US Census).

# Jurisdiction or Target

# Other resources utilized: N/A
Factors essential to implementation: The program partially credits the success of the maps to careful planning and testing to ensure that the messages were clear for the desired audiences. To this end, WI CLPPP pilot-tested the materials with nurses, health educators, and sanitarians from local health departments' lead program staff. The state is currently exploring the feasibility of offering online access to GIS mapping, through which the public would be able to customize maps of lead data in combination with various other types of data.
Limitations/challenges/problems encountered: None mentioned.
Magnitude of Impact/Potential Impact: Wisconsin created maps with 3 views for all of its 72 counties and the larger cities, enabling them to show separately the areas with low (0 -30 percent pre-1950 housing), medium (30 -60 percent), and high (60 -100 percent) densities of older housing. The resulting maps were powerful communication tools showing strongly that those with lead poisoning are predominately found in the areas with the highest proportion of pre-1950 housing.
Although the maps were relatively straightforward in the sense that they only mapped one familiar risk factor (age of housing), feedback on the maps has been universally positive, with continuing requests for customization. At least one jurisdiction used them to target properties for HUD lead hazard control funding, and the city-level maps positioned cities for collaboration and communication about the use of Community Development Block Grant (CDBG) funds for prevention. Even private managed care organizations have requested detailed maps for their service areas, as they reportedly do not have GIS capability themselves. An unsolicited feedback letter from an insurance company requesting additional maps commented that they "were a real visual learning experience for our head Pediatrician and, interestingly, ... his nurse   and training and any applicable credentials to provide lead education services, hazard determination, and lead hazard control services.
Cost considerations: Such intensive service delivery can be expensive: $300-400 for a risk assessment, $500 20,000 for lead hazard control, $150 for a clearance examination. Federal Medicaid policies allow reimbursement for environmental investigation and case management services. However, at present some state Medicaid programs have not begun reimbursing for these services despite explicit federal encouragement to do so. Lead hazard control can be funded by a variety of sources.

# Timing issues:
Program could be implemented whenever resources, referral mechanisms, regulatory compliance measures, and service providers have been secured.

# Feasibility of Implementation:
Moderate. This is an ambitious program requiring strong community commitment, significant resources, and ongoing collaboration among disparate entities. Beginning with a pilot program is one means to establish relationships and test systems.

# POTENTIAL OBSTACLES/BARRIERS
This project requires considerable coordination and cooperation between various agencies and entities including health, housing, and the state Medicaid agency. It would likely be difficult to acquire the resources and support for this type of project in a situation where adequate environmental responses are not available to families whose children have even higher blood lead elevations (above 20 g/dL).

# ADDITIONAL RESOURCES

# Factors essential to implementation:
The tenacity of the Get the Lead Out Coalition in promoting the project and the willingness of the project partners to work collaboratively were essential.
Limitations/challenges/problems encountered: This initiative is limited to properties occupied by Medicaid families with young children or pregnant women, and targeted to eleven Connecticut cities with large numbers of Medicaid enrolled children but limited or no funding for lead hazard control.

# Magnitude of

# POTENTIAL OBSTACLES/BARRIERS
The experience of the Massachusetts Department of Public Health (DPH) is illustrative of some difficulties associated with this strategy. While its regulations authorize the health department to conduct building-wide investigations, the agency does not routinely do so because of concern that generating multiple orders for correction of hazards will divert the owner's resources from addressing the unit that has poisoned a child. As an alternative, DPH notifies all tenants in a building about an inspection, advising that lead was found in one unit, it is likely that their unit has lead, and they should talk to the owner or call the state or local board of health if they want an inspection. Upon tenant request, DPH does an investigation. Additionally, DPH will investigate other units in those jurisdictions where local financing agencies in Massachusetts will assist owners with abatement of all units in the building at once. Massachusetts is revisiting its strategy for multi-unit buildings as it develops its CDC-required strategic plan. Limitations/challenges/problems encountered: Securing the resources to pay for environmental investigations has been the biggest challenge. Although not a common problem, inspections occasionally create conflict between landlords and tenants. Although Maine law specifies that a household cannot be evicted due to a child's lead poisoning, Maine is considering strengthening tenant protections against landlord retaliation.

# ADDITIONAL RESOURCES
Magnitude of Impact/Potential Impact: Program staff estimate that 250 multi-family buildings have been investigated after the identification of a lead-poisoned child in one of the units since the 1999 law was enacted.
Potential for replication: High.

# SCREEN HOMES DURING CODE INSPECTION DESCRIPTION OF THE STRATEGY
Code inspections prompted by complaints about housing problems such as a roof leak, roaches, or no heat, as well as routine periodic inspections of rental housing units, provide opportunities to screen for lead hazards and peeling paint in the homes of young children. Code enforcement staff can be specially trained to conduct limited checks for lead hazards as a means to trigger additional action. If the inspection identifies a lead hazard through visual assessment, spot testing, dust testing, or paint testing, the inspector can order the property owner to undertake lead hazard control or lead-safe repair work to bring the unit into compliance with any applicable standards.

# BENEFITS
Immediate/Direct Results: The number of homes checked for lead hazards can be greatly increased at comparatively low cost by integrating basic lead safety checks into other code inspection visits. By checking homes for lead hazards and requiring corrective action consistent with applicable standards, code enforcement programs help reduce the risk of childhood lead poisoning. Public Health Benefits: In most jurisdictions, the lead poisoning prevention program sends environmental investigators only to the homes of children who have been lead poisoned. In contrast, code inspectors have the opportunity to enter many homes, and they can identify hazards before a child is exposed and an elevated blood lead level develops. Their code enforcement authority can be used to routinely intervene to require lead safety in the highest risk older properties-those that are subject to tenant complaints about poor maintenance or other health conditions. Other Indirect/Collateral Benefits: This approach leverages limited public inspection resources to trigger lead hazard assessment control. Strong enforcement broadens impact of the code enforcement program, prompting property owners to undertake voluntary measures in other properties and perform preventive maintenance on all rental housing.

# SCOPE OF POTENTIAL IMPACT

# CRITICAL ELEMENTS
Staff requirements: During the start-up phase of a statewide program, approximately 0.75 FTE is needed to establish procedures and build trained capacity. For an established program, 0.3 FTE is needed for program oversight and one FTE for technical assistance to local agencies (code agency and health department). For local agencies, each individual who conducts housing inspections should be trained to perform lead determinations. Depending on the sampling method used, checking for lead hazards will add 10-30 minutes to the typical housing inspection. Staff requirements to meet the workload will depend on the type of determination, which is affected by what the standard is: no peeling or otherwise non-intact paint in any housing, no lead dust hazards, etc. Depending on the extent of lead hazards, the standard to be met, the type of enforcement action, and the local or state court rules, additional time is also required for enforcement steps, including court appearances. Inspectors represent themselves at hearings before clerk magistrates or judges, as they already do for other code enforcement cases. Involvement of public agency attorneys is generally needed only for cases that progress to the criminal complaint stage.
Other resource requirements: Supplies or equipment to check paint; supplies and lab services to check dust.

# Institutional capacity required:
This strategy requires authority to require compliance with an explicit standard (e.g. no peeling or otherwise non-intact paint in any housing, no plumbing leaks, no lead dust hazards), such as statutory lead safety requirements for housing or locally adopted property maintenance code. The statutory authority should cover licensing or certification of code inspectors or categorically exempt trained inspectors employed by public agencies from licensing or certification requirements. Implementation needs include training curricula, and, as needed, training providers approved by an accreditation program to teach the curriculum. Continuing partnership between agencies that regulate lead-based paint activities and those that enforce codes will ensure effective implementation.
Cost considerations: The program will be more effective if resources are available to assist low-income property owners with the cost of lead hazard control and provide favorable financing terms to others.
Timing issues: Can be implemented whenever infrastructure is in place.

# Feasibility of Implementation:
Moderate. In jurisdictions that have code enforcement apparatus and enforceable lead safety standards, this can be implemented wherever political will is sufficient to support enforcement. Enforcement can include requiring interim lead hazard controls rather than full lead hazard abatement, so as to decrease costs of compliance when code violations are found.

# POTENTIAL OBSTACLES/BARRIERS
Lack of legal authority and absence of enforcement standards can be insurmountable barriers. Enforcement includes a single brief inspection and may involve multiple court appearances by the inspector to trigger and complete the legal process of enforcement. Two potential obstacles are the unwillingness of the city/county attorney to prosecute cases and the difficulty agencies may face in maintaining a presence in court throughout the entire enforcement process. State health departments could loan lawyers to prosecute and/or provide technical assistance to local agencies on request.

# ADDITIONAL RESOURCES N/A

# ILLUSTRATION OF STRATEGY IN PRACTICE
Code enforcement staff who respond to complaints about housing problems such as a roof leak, roaches, or no heat, as well as routine periodic inspections of rental housing units are specially trained to conduct limited checks for lead hazards as a means to trigger additional action. If the inspection identifies a lead hazard through visual assessment, spot testing, dust testing, or paint testing, the inspector orders the rental property owner to undertake lead hazard control or lead-safe repair work to bring the unit into compliance with any applicable standards.

# Jurisdiction or Target

# ILLUSTRATION OF THE STRATEGY IN PRACTICE
Title 6 of the Philadelphia Code and Regulations gives the Department of Public Health (DPH) the authority to issue correction orders to owners (or their agents) of housing units found to have lead-based paint hazards. If an owner does not comply with the order, the City files a case in Philadelphia's special "lead court." The city may seek a range of remedies, including the use of City funds to abate the hazard and recovery of those costs from the owner. If the property owner fails to reimburse the city, the court may place a lien on the subject property for the amount of abatement costs and other related expenses. This process has been a powerful motivator for property owners, who are now more likely to proactively correct lead hazards-or at least comply with orders before the case gets to court. Staffing utilized: There are no staff dedicated to implementing this strategy. When abatement is needed, crews from the city's lead hazard control program can be assigned and the labor cost is included in the amount billed to the property owner or added to the lien.

# Jurisdiction or Target

# Other resources utilized:
The Department of Health provides justification for the cases, including lead inspection checklists and laboratory records on EBLs. The Law Department also has access to a list of property owners who have requested assistance.

# Factors essential to implementation:
The combination of a dedicated lead court, consistent enforcement, and outreach to landlords to make sure they understand that they must comply or they will be prosecuted enables the City to avoid using this strategy.
Limitations/challenges/problems encountered: The City is unlikely to recover the costs of lead hazard control because homes with deferred maintenance and serious hazards, which often already have tax liabilities or other liens attached, sell for as low as five to ten thousand dollars. As a result, this measure is used only when owners qualify for no other programs. Also, determining the identity of the property owner is sometimes challenging and takes a considerable amount of time.
Magnitude of Impact/Potential Impact: The provision has not been used because the Law Department has been able to use other means to resolve the 1,700 cases that it has filed with the Court.

# CONDUCT PERIODIC HOUSING CODE INSPECTIONS DESCRIPTION OF THE STRATEGY
Code enforcement systems that operate solely in response to tenant complaints, although the prevailing norm nationwide, are highly ineffective and have limited impact. This approach fosters the decline of rental housing conditions since tenants may not know how to register complaints or may be reluctant to complain out of fear of retaliation by the landlord. In contrast to sole reliance on complaint-based approaches, proactive, periodic inspection programs can advance primary prevention more meaningfully. Both New Jersey and Los Angeles have committed to inspecting multi-family rental properties every three to five years. Such preemptive code inspections also can be more narrowly targeted to high-risk neighborhoods, as the City of Milwaukee is doing.

# BENEFITS
Immediate/Direct Results: Problems such as lead hazards are routinely identified by an inspection, documented, and brought to the attention of the rental property owner. Code officials can ensure that when housing code violations are corrected, the work is done in a lead-safe manner. Public Health Benefits: A periodic rental housing inspection program helps to ensure that multi-family rental housing units comply with basic health and safety standards. Periodic inspections foster pro-active maintenance because property owners cannot expect to remain "outside the system." By promoting routine preventative maintenance on a widespread basis and improving the quality of the rental housing stock, periodic inspection programs can help to prevent lead hazards-even in rental housing units that would be missed under a complaint-based inspection program.
Other Indirect/Collateral Benefits: Periodic inspection programs, when coupled with an effective enforcement regimen, can generate fees sufficient to offset the cost of the program. Regular inspections help to maintain the quality of the rental housing stock over the long term in a cost-effective manner.

# SCOPE OF POTENTIAL IMPACT
Statewide-Impact depends upon the scope of the housing code inspection program City-or County-Wide Neighborhood/Community

# PRIMARY ACTORS KEY PARTNERS
Code or Building Inspection Agency Health Department Local Prosecutors Community-based Organizations Property Owners Tenants

# CRITICAL ELEMENTS
Staff requirements: When moving from a complaint-based inspection program to a periodic system, additional inspectors may initially be required because a periodic inspection program also must accommodate complaints. Under an effective periodic inspection program, the number of complaint-based inspections will decrease over time. Where periodic inspections have been mandated, few inspections are undertaken in response to complaints. In New Jersey, for example, periodic inspections have been mandated for over thirty years, and few inspections currently are undertaken in response to complaints. Under the state's periodic inspection program, approximately 115 inspectors conduct approximately 162,000 inspections in dwelling units annually and re inspect about 127,000 of those units. Staffing utilized: More than 57 inspectors devote their time solely to proactive inspections. An additional 22 inspectors respond to tenant complaints. Some of the inspectors that deal with complaints also assist with reinspections in units found to be out of compliance during the scheduled inspections.

# Other resources utilized: N/A
Factors essential to implementation: Successful implementation of a periodic inspection program requires, first and foremost, adequate staff to carry out inspections. Inspectors must be well trained, not only to identify code violations, but also to deal effectively with tenants. In Los Angeles, advocates have conducted trainings for inspectors to help them deal with cultural and/or language issues that may arise with tenants.
Another key to the success of the SCEP program is that a loan program has been put in place to help small landlords make repairs. Finally, effective enforcement is critical to the success of a periodic code inspection program. While the city experienced some initial problems with cases stalling in the courts, hearing officers are increasingly successful at moving cases forward. In addition to a commitment to enforcement on the part of agency staff, adequate prosecutorial resources must be dedicated to enforcement.
Limitations/challenges/problems encountered: Initially, obtaining funds for the program was a challenge. However, the City increased the monthly inspection fee that rental property owners pay.
Magnitude of Impact/Potential Impact: The current schedule for inspections allows for rental units to be inspected every five years. Each year, about 150,000 units are inspected. However, the city hopes to increase that figure to 180,000.
Potential for replication: Very high. These programs are readily replicated.

# Contact for Specific Information:
Greg

# ENABLE TENANTS AND COMMUNITY-BASED ORGANIZATIONS TO TAKE ACTION TO ADDRESS SUBSTANDARD HOUSING CONDITIONS DESCRIPTION OF THE STRATEGY
In many cases, tenants lack the ability to address substandard housing conditions or are reluctant to exercise their rights out of concern that the landlord will retaliate. Empowering tenants to take action when housing conditions are inadequate and enabling neighborhood organizations to act on tenants' behalf can significantly enhance the efforts of code enforcement officials. One effective strategy is to legally enable tenants or their advocates to request a code inspection and empower them to pursue enforcement actions themselves in court. This approach also helps circumvent the common problem of inadequate resources for enforcement.

# BENEFITS
Immediate/Direct Results: Tenants in substandard properties obtain legal standing to initiate code inspections, enforcement, and remediation actions without fear of landlord retaliation. If receiverships (court appointment of third party administrators to manage properties and oversee repairs) or rent escrow arrangements are permitted, rents can be used directly to fund repairs. Public Health Benefits: High-risk housing is targeted for repairs that reduce health hazards. Code agency and/or court oversight can ensure that repairs are done safely and following accepted protocols and without hazards being left behind.
Other Indirect/Collateral Benefits: Tenants gain power in relation to landlords, which could result in landlords community-wide becoming more responsive and proactive regarding maintenance and repairs.

# SCOPE OF POTENTIAL IMPACT

# CRITICAL ELEMENTS
Staff requirements: An experienced organizer could, in several months, organize a campaign capable of enacting such a law. One or more FTE (organizers, attorneys) could staff a project to assist tenants with using the process in just one community. Enacting a new state or municipal law to give legal standing for tenants in substandard properties to initiate code inspections/enforcement and take enforcement actions themselves can be a major undertaking.
Other resource requirements: Research would be needed on existing laws, as well as on the degree and extent of substandard housing conditions in the jurisdiction and specific shortcomings of the existing code enforcement system. Institutional capacity required: An organization undertaking such a campaign would need the capacity to organize and lobby, experienced staff, and relationships with allies among tenants' rights, affordable housing, public interest, legal, and other community organizations.

# Cost considerations:
The positive impact on housing affordability and condition is potentially great. These benefits will far exceed the cost of a campaign to secure enabling legislation. Creating and funding an organization or agency to provide ongoing assistance to tenants bringing enforcement cases should be considered, as this will greatly improve the impact of the law and the quality of outcomes.

# Timing issues: None
Feasibility of Implementation: Variable. Any organization undertaking such an effort should understand that because of the complex and unpredictable nature of the legislative process, the degree of difficulty may be greater than expected and success is not guaranteed. Pilot programs with limited scope may be a useful first step, giving advocates time and resources to prove that the strategy is effective in a target area.

# POTENTIAL OBSTACLES/BARRIERS
This strategy requires enacting new legislation, working to ensure that it is effectively implemented, and ongoing work to assist tenants with using the process. Thus, this strategy is a major undertaking and could fail if sufficient resources and energy are not available to overcome inertia and political opposition.

# ADDITIONAL RESOURCES
N/A

# ILLUSTRATION OF STRATEGY IN PRACTICE
Minnesota's landlord-tenant law, Chapter 504B, allows tenants, a municipality, or a neighborhood housing-related organization legal standing to bring a court action against a landlord who fails within a reasonable time to correct deficiencies at their property. Project 504, a non-profit neighborhood organization, has brought more than ten such cases in the past three years, leading to broad remedies for tenants, including in some cases the appointment of a third-party administrator to manage and operate the landlord's property. Project 504's court action also established precedent that significant unabated lead hazards in a property constitute an emergency, causing the court to issue orders to the landlord to correct the hazards immediately. Factors essential to implementation: Strong partnership with other affordable housing and tenant advocacy organizations. Code enforcement officials who recognize that the strategy's success will reduce enforcement time spent on problematic properties. Strong and ongoing relationships with tenants, including any identified tenant leaders who will advance the strategy. Solid knowledge of landlord-tenant law, or partnership with pro bono or legal services attorney who can provide legal analysis and support. Relationships with proactive landlords who recognize the need to address substandard housing in their jurisdiction are also helpful.

# Jurisdiction or

# ILLUSTRATION #2 OF STRATEGY IN PRACTICE
An ordinance passed in 2002 gave code inspectors the authority to pursue charges against property owners who do not treat lead-based paint hazards in their buildings. The City of Kankakee's Community Development Agency's Lead Poisoning Prevention Program (LPPP) trained code inspectors to visually assess and identify lead hazards. When code inspectors discover an existing or potential lead hazard, they can refer the property owner to the LPPP. Through its HUD Healthy Homes grant, the program helps property owners make repairs before a hazard develops, as well as remediate or abate existing hazards. Property owners who do not follow up on the voluntary referral are cited. Other resources utilized: No information provided.

# Jurisdiction or Target

# Factors essential to implementation:
A good relationship with the code enforcement division is key. Outreach to property owners through local landlord association allowed them to address concerns up front as well and educate property owners about lead hazards before inspections. HUD Healthy Homes and CDBG monies provide the funding to assist property owners in lead-safe work practices and lead hazard remediation.
Limitations/challenges/problems encountered: Occasionally a property owner doesn't recognize the seriousness of the problem, but the LPPP grants typically alleviate any objections. Nominal outreach was needed to bring the Code Enforcement Division and the Health Department together, since each agency has its own focus.
Magnitude of Impact/Potential Impact: LPPP receives an average of 20-25 referrals per month. In its first two-year grant cycle, it assisted 300 properties and will complete another 240 this cycle. As a result of interactions with code inspectors, other property owners voluntarily contact LPPP for lead hazard information and assistance. Outreach coordinators have seen a shift in community awareness also, from landlord association meetings to WIC outreach.

# Potential for replication:
Moderate. This strategy can be replicated wherever there is a property maintenance code that the city is willing to enforce. Approximately 25% of the owners contacted via letters have attended dinners, and GHC is starting to receive responses from previously uncooperative owners.

# Contacts for Specific Information
Jenny
Jurisdiction or Target Area: Greensboro, North Carolina Primary Actor: Greensboro Housing Coalition (GHC) Secondary Actor(s): N/A Staffing utilized: 0.25 -0.5 FTEs for four mailings and eight dinners, including researching and preparing the mailings and planning for and convening the dinners.
Other resources utilized: Data sources include information collected during GHC's neighborhood outreach and hazard assessment activities (as a subcontractor to CEHRC and the city's lead hazard control program), the city's housing code enforcement database, and the tax assessor's database. GHC uses a laptop and digital projector for presentations. A transitional housing program with a large community room donates space for the meetings. Food is purchased and prepared by GHC staff.

# Factors essential to implementation:
A key factor is good working partnerships with the range of agencies that need to communicate with landlords about their responsibilities under federal, state, and local laws, and resources available to help them make their properties lead-safe.
Limitations/challenges/problems encountered: The majority of landlords have not yet responded to the letters. Also, it has been difficult to identify and locate some owners. It is difficult to determine owners' follow up activities for two reasons: the city's lead hazard control program is overwhelmed and cannot always provide accurate and up-to-date information on the applications received; and the owners tend to not readily provide information on what, if any, steps they have taken to control lead hazards.
Magnitude of Impact/Potential Impact: Many more owners of high-risk housing are following the disclosure law. At least 25 properties have been enrolled in the city's lead hazard control grant program.

# Potential for replication: Moderate

# Contact for Specific Information
Beth McKee-Huger Executive Director 336-691-9521 rachelltv@aol.com

# References for additional information N/A

# ILLUSTRATION #4 OF STRATEGY IN PRACTICE
Project 504 built an extensive database of owners of pre-1950 properties in high-risk neighborhoods and is using it to mail out at least 1,000 boilerplate and 250 registered letters. Owners receiving boilerplate letters first receive a postcard to alert them to the coming letter. The postcard serves two purposes: getting the property owners' attention and culling bad addresses from the database before the more expensive letters are sent. Both the postcard and the letters refer owners to Project 504's new website designed to provide resources to property owners, www.nomorelead.org. When rental property owners contact Project 504 for more information, they are sent a letter with an accompanying stamped postcard that the owner can send directly into the county for more information on how to enroll in the lead hazard control (LHC) grant program. The county saves these cards