JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Lead Assessment
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Resident Name
Your answer
Address
Your answer
Contact Number
Your answer
Email Address
Your answer
Owner or Renter
Homeowner
Renter
Other:
Clear selection
Yes I need to have my water tested for lead
Yes
No
Clear selection
Type of Home
Single Family
Multi-Unit
Double
Clear selection
Was the home built before 1978? What year approximately?
Your answer
Total Number of Residents in Household
Your answer
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
Pets
Other:
Required
Does anyone work or have hobbies in the following?
Construction
Painting
Car Repair
Maintenance Workers
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
Your answer
Has anyone inside the home tested positive for lead poisoning? If so, who, when, and at what age.
Your answer
Do you buy bottled water?
Yes
No
Clear selection
Do you have a water filter installed on the Kitchen sink or a full house water filter? If so, please provide location and type.
Your answer
Has the city done any recent water repairs on your street? If so, when and where.
Your answer
Next
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms
