Weatherization Client Consent and Acknowledgement Form

Weatherization achieves energy and cost savings and improved comfort, health, and safety of homes through a variety of home retrofit measures, including some that improve the airtightness of the building. According to the U.S. Department of Energy (DOE) sponsored study, “Weatherization and Indoor Air Quality: Measured Impacts in Single-family Homes under the Weatherization Assistance Program,” there is a small risk of increased radon levels in homes when the building air tightness levels are improved. These increases are smaller in manufactured housing everywhere, and all homes in low-radon potential counties, and higher in site built homes in high-radon-potential counties. There is some evidence that the installation of continuous mechanical ventilation reduces radon levels in homes, and counteracts any radon increases that are due to improved building air tightness levels.

I am aware that weatherization may result in increased levels of radon, and that mechanical ventilation may counteract those increases. I have received the U.S. Environmental Protection Agency’s (EPA) “A Citizen’s Guide to Radon” and radon-related risks were discussed. I have chosen to go forward with weatherization, and I accept all risks of injury or damages.

Please be advised that the use of airborne insulation and/or two-part foam may be hazardous to your health. Individuals with respiratory and breathing disorders should exercise extreme caution when the possibility of contact with insulation and/or two-part foam is imminent.

Because of the threat of possible illness resulting from the use of airborne insulation and/or two-part foam, the Agency requires that all occupants of the household with potential illnesses, vacate the premises during the insulation process.

The agency will install cellulose insulation that is blown and/or two-part foam under the following terms and conditions:

1. The premises must be vacated of individuals with potential illnesses that could be exacerbated or caused from the installation of insulation and/or two-part foam and must remain so for a reasonable time after installation.

2. The agency must be notified of anyone with respiratory/breathing problems or problems of past respiratory illnesses. (the agency may choose to use alternative insulating materials).

3. The agency will not assume responsibility or liability for any alleged injuries/illness resulting from the installation of insulation or two-part foam for failure of occupants to follow the warnings.

By signing this form, I acknowledge I have received a copy of the above warning and understand the nature of these warnings, and all members of the household agree to comply with the warnings.

By signing this form, I understand the information provided and release the agency from any liability frm complaints issued after the one-year period.

A Major Measure is defined as a high priority measure, which if skipped, would result in partial weatherization of a unit. Major measures are as follows: air sealing, duct sealing of ducts outside the thermal boundary, attic insulation, wall insulation and floor or belly insulation (WPN 19-4, attachment 8).

The Agency, as part of client education, has informed the client of planned measures and material use. By signing below, the client agrees to the installation of the work scoped in the energy audit. If during the installation process, the client declines a major measure, work must stop at the time the client declined the major measure. No further installation is allowed, and the job must be inspected by a QCI and closed out as a completed unit. This must be clearly explained and documented in writing in the client file with signatures from the client.

By initialing and signing below, I have carefully read this client consent and acknowledgement form, have received all pamphlets and information mentioned in this form and have signed it of my own free will.