Healthcare Asbestos Survey

HEALTHCARE ASBESTOS SURVEY

Survey Identification

Survey Date:   Facility Name:

Facility Address:

Building/Unit:   Floor:   Room/Area:

Survey Performed By:   Company:

Patient Information

Insurance Information

Medical History (relevant to exposure)

Asbestos Assessment — Observed Materials

Sampling and Laboratory Results

Date Sampled:   Sampling Method:

Result Date:   Analytical Method:

Recommendations and Work Priority

Inspector Certification and Observations

I hereby certify that the inspection and sampling described in this report were performed under my direct supervision, in accordance with standard industry procedures, and the observations set forth herein are true and accurate to the best of my knowledge. Sampling is representative of the specific locations sampled and does not constitute a survey of untested areas. Recommendations are based on conditions observed on the date of inspection.

Limitations, Liability and Records

Scope and Limitations: This survey documents visible and accessible materials present at the time of inspection. Non-visible or concealed asbestos-containing materials are not reliably assessed without additional invasive sampling. Laboratory results apply only to the individual samples submitted for analysis. This report does not warrant or certify that all asbestos hazards have been identified.

Liability and Reliance: The surveyor and surveyor's employer are not responsible for work performed by third parties pursuant to this report. The client retains responsibility for implementing recommended controls and for notifying contractors of asbestos presence. Any actions taken contrary to recommendations are at the client's risk.

Records Retention and Disclosure: Survey records, chain-of-custody documentation, and laboratory reports will be maintained in accordance with applicable record retention policies. Confidentiality of patient-identifying information will be maintained; distribution of this report is restricted to authorized personnel and representatives.

Acknowledgment of Receipt

Patient/Authorized Representative acknowledges receipt of the findings of this asbestos survey and understands the recommendations and limitations stated herein. Acknowledgment does not imply acceptance of abatement work performed by the surveyor.

Acknowledgment: I acknowledge receipt of the asbestos survey results.

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