LDSS-7041. Directions for Completing the Environmental Hazards Statement

Form LDSS-7041, the Environmental Hazards Statement, is a form used to evaluate any potential environmental hazards present in a home or other residence. It is used by the New York State Office of Children and Family Services to assess the safety of a home in order to determine if a family or individual is eligible to receive certain services or benefits.

The form consists of several sections including a general household information section, an environmental hazard assessment section, and a signature section. The general household information section requests basic information regarding the home, such as the address, date of inspection, and type of residence. The environmental hazard assessment section requests information about any potential environmental hazards present in the home, such as mold, asbestos, lead, or other hazardous materials. Finally, the signature section requires a signature from the inspector to verify that the information provided is accurate.

Important fields in this form include the address of the home, the date of inspection, and the inspector's signature. It is important to accurately complete this form, as any false or inaccurate information could result in the denial of services or benefits.

An example situation where the form would be used is when a family is applying for assistance from the New York State Office of Children and Family Services. In order to be eligible for assistance, the family must first have their home inspected for any potential environmental hazards. The Environmental Hazards Statement is used by the inspector to document the results of the inspection.

Specific instructions for filling out the form include providing accurate and complete information, and ensuring that the signature section is properly completed and dated. Additionally, related forms or alternatives include the NYS Environmental Hazards Survey, which is used to assess potential environmental hazards in a home, and the NYS Environmental Hazards Notice, which is used to inform occupants of any potential hazards in the home.