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The Florida DH 1777 form serves as a crucial document for nonresidential radon measurement reporting in various types of facilities, including assisted living centers, hospitals, and schools. This form is required to ensure compliance with state regulations regarding radon exposure and safety. It collects essential information about the facility and its owner, including names, addresses, and contact details. Additionally, the form requires specific building information, such as the number of stories, age of the building, and foundation type. Measurement details are also included, allowing for tracking of radon levels over time. The form differentiates between initial measurements and follow-up tests, providing a comprehensive overview of radon testing activities. Furthermore, it allows for certification by the measuring specialist or facility staff, ensuring accountability in the reporting process. Upon completion, the form must be submitted to the Department of Health's Bureau of Environmental Health, either by mail or electronically, to maintain compliance and safeguard public health.
Form Example
Bureau of Environmental Health
Radon Program
Mandatory Measurements
NONRESIDENTIAL RADON MEASUREMENT REPORT
FOR BUILDINGS OTHER THAN SINGLE OR MULTI FAMILY DWELLING
Page ___ of ___
SECTION 1: FACILITY AND OWNER INFORMATION
Facility Information: |
Owner Information: |
Facility Name (as licensed, registered, or listed with state)
Physical location (Street Address) of Facility Site
City |
County |
Zip |
Name of Contact Person
Name of Owner
Street Address
City |
State |
Zip |
()
Phone Number
()
TitlePhone Number
Facility type as licensed or registered (Submit individual facilities separate. I.E. A Day Care and School at the same place):
Assisted Living Facility (previously ACLF) |
Hospitals (Acute Care, Physical Rehab., Psychiatric, or Intensive |
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Alcohol, Drug Abuse or Mental Health |
Residential Treatment) |
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Correctional Facility or Jail |
Nursing Home/Skilled Nursing Facility |
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Day Care Center (pre kindergarden) |
Public School |
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Delinquency Program (Ex: Start Center, Training School) |
Private School |
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OTHER (specify) |
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SECTION 2: BUILDING INFORMATION
Building Name or ID Number (If Applicable)Street Address of Building (If Different From Facility Site)
Buildings per address ___; Building No. ___ of ___ requiring testing.
Number of measurements required in this building during this testing period: ______ initial or 5 year retest, ______
Cumulative number of measurements reported for this testing period: ______ initial or 5 year retest, ______
____ No. of Stories, ____ No. of Stories Occupied, ________ Age of Building in Years (or year built)
Foundation/Floor
System:
Slab
Crawlspace
Pier
Floored Basement
Bare Earth Basement
Other(specify)
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CHECK ALL THAT APPLY |
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HVAC System: |
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HVAC: |
Other HVAC: |
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(system with fresh air intake) |
(system without fresh air intake) |
Window/Wall Unit |
Single Zone / single |
Central Ducted A/C |
No A/C |
return |
Central Ducted |
No Heat |
Multiple Zones / |
Heat |
Other (specify) |
multiple returns |
Space Heater |
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For Official Use Only:
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Date |
Reviewed |
Entered |
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Received |
By |
By |
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DH 1777, Edition 7/15 (Replaces Jan 93 Edition)
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SECTION 3: RESULTS |
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Measurement Type: Initial or 5 Year Retest, |
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Dates of Measurement: FROM |
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TO |
/ / |
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Name of Person who performed Measurement (Placed Device) |
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† |
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Certificate No. (If Applicable) |
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‡ |
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Story |
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Room |
Result |
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Units |
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Device |
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Time in Hours |
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† P for pCi/L or W for WL
‡
SECTION 4
COMPLETE ONLY IF MEASUREMENTS ARE PERFORMED BY A RADON MEASUREMENT BUSINESS
Name of Business and Cert. No. |
Name of Specialist and Cert. No. |
Signature of Specialist
SECTION 5
COMPLETE ONLY IF MEASUREMENTS ARE PERFORMED BY STAFF EMPLOYED BY THE FACILITY
I hereby certify that the Radon measurements reported herein have been performed in accordance with Chapter
Authorized Representative of Facility |
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Date |
Upon completion of this form, send to:
Department of Health
Bureau of Environmental Health / Radon Program
4052 Bald Cypress Way, Bin #A12
Tallahassee, FL
You may scan the report and email it to RadonReports@FLhealth.gov
For Assistance in Completing this Form call
Document Breakdown
| Fact Name | Description |
|---|---|
| Form Purpose | The Florida DH 1777 form is used to report radon measurements in nonresidential buildings, ensuring compliance with health regulations. |
| Governing Laws | This form is governed by Chapter 64E-5 of the Florida Administrative Code and Chapter 404 of the Florida Statutes. |
| Submission Requirements | Facilities must submit individual forms for each building requiring testing, including specific details about the facility and owner. |
| Measurement Types | Measurements can be categorized as initial, 5-year retests, or follow-ups, with detailed results required for each testing period. |
| Contact Information | The form requires contact information for both the facility and the owner, including names, addresses, and phone numbers. |
| Result Reporting | Results must be reported in specific units, such as pCi/L or WL, and must include the name of the person who performed the measurement. |
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