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| Form Number:  DLA1867                                                                    |
|------------------------------------------------------------------------------------------|
| Form Title:  Self-Certification Home Safety Checklist                                    |
| Form Version:  Feb 2003                                                                  |
| Status:  Active                                                                          |
| Functional Area:  Human Resources                                                        |
| Opr:  J1                                                                                 |
| Safeguards:  PII                                                                         |
| Electronic:  Yes                                                                         |
| Form Link:  Documents/FormsSite/forms/DL1867.pdf                                         |
| Type:  Primary                                                                           |
| Prescribed:  n/a                                                                         |
| Description:  This form is used to conduct a self-certification home safetey inspection. |
| Records Retention:  coming soon                                                          |
| Form Audience:                                                                           |

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