Owner or Renter
Was the home built before 1978? What year approximately?
Total Number of Residents in Household
Number of Residents In Household who spend at least 3 or more hours a week inside the home
Adults over 65
Children between age 13 and 18
Children between age 6 and 12
Children Under 6
Adults between age 19 and 64
Does anyone work or have hobbies in the following?
Are you concerned about any of the following?
Funny tastes, smells or look of water coming out of facuet
Flooding inside my home
Flooding on my street
Please share any details you would like on the household members i.e. specific ages, number of children, types of pets
Has anyone inside the home tested positive for lead poisoning? If so, who, when, and at what age.
Do you buy bottled water?
Do you have a water filter installed on the Kitchen sink or a full house water filter? If so, please provide location and type.
Has the city done any recent water repairs on your street? If so, when and where.
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