Visual Review / Dust Sample Collection & Analysis

Instructions for MDE Form C – Visual Review / Dust Sample Collection & Analysis


A.) Enter the MDE Tracking Number. The tracking number was formerly known as the MDE Owner Number. 

The property owner, NOT the inspector, should call MDE at 800-776-2706 or 410-537-4199 to receive a number or verify an existing number.  This is the number that the property owner will use to register their rental properties each year.


B.) Enter the date of the inspection which is the date that you collected the dust samples. 

If the Form C is being completed due to a retest, within 30 days of the initial inspection, then two (2) forms C should be submitted with the certificate. 

One form C for the original dust test and one Form C for the retest, along with both sets of Laboratory Results.


C.) Enter the Inspection Certificate Number that is preprinted on the Form 330.

D.) Fill in the address including the unit number per the instructions in the Unit Naming Guidance and include the county or city. (e.g. AA for Anne Arundel, B. Co for Baltimore County, or B. City for Baltimore City).


E.) Enter the date of the lab report which is generally the date the samples were analyzed at the lab.


F.) Enter the date in which you (the inspector) actually receive the lab report from the laboratory.


G.) Circle YES or NO to indicate whether or not the interior and exterior paint is in satisfactory condition.

You may proceed with dust testing only if paint conditions are satisfactory, unless there is an Exterior Waiver (Seasonal Waiver).  The Exterior Waiver (Seasonal Waiver) only applies to the exterior paint conditions.


H.) Circle YES or NO to indicate whether or not an Exterior Waiver (Seasonal Waiver) was issued.

You must contact the local code enforcement office in all other municipalities to receive a written waiver. A list of municipal contacts is available on the Inspectors and Contractors page on the MDE website. 


Enter the year in the blank after 4/ 30/________, this is when the certificate expires. 

If the exterior work is not completed and verified by re-inspection by the expiration date, the certificate expires.

A Supervisor’s Statement of Work must be submitted with a Form D for the re-inspection.

If the certificate expires, the whole inspection process must be repeated and a new certificate must be issued.


J.) Enter the name of the Agency or Official that approved the Exterior (Seasonal) Waiver.

The owner and inspector should keep a copy of the waiver. MDE may request a copy of the waiver.


K.) Complete a diagram on a separate sheet of paper as follows:

Show the street name (with unit ID) adjacent to the outside entry door.

Show each room within the unit and number (or letter) each room.

Mark the location of the windows in each room with a (W).

Use numbers, letters, or X’s to indicate the location where dust samples were collected within each room. (see sample attached) L.) Circle YES or NO to indicate whether or not the Form C is being submitted as the result of a retest.


M.) For Part III of the Form C, enter the Certificate (Form 330) number and page number on every page of Part III that you submit.  You may attach as many pages of Part III as necessary to list all laboratory results.


N.) Enter the information from the field blank per the instructions on the Form C.


O.) Complete this section fully and accurately.

Include the Room # from the diagram.

Enter the number of Non- lead free windows, the number lead free (or other) windows, and the total number of windows in the room. The total should equal the number of lead-free plus the number of other windows.

Other windows are windows that would not require a well sample; for example, a casement window.

Enter the sample numbers, areas (in inches), and the results (µg/ft2) in the box for each room.

If more than one sample is collected in a room, the results can be entered in the same room box. (e.g. a well and floor sample) 


P.) Enter the date in which you completed the Form C.

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