Property address
Property is:
Mortgage (yes / no)
Complete the following information if the property is a Single Family Home
Number of bedrooms
Number of adults
Number of children
Number of children under 6 years old
Tenants name
Tenants gross income
Complete the following information if the property is a Multi-Family Home
Property owner's name
Address
City, State, Zip Code
Telephone Number
Alternate telephone number
Email address
Children under age 6 with identified EBLL (over 5 ug/d)
Pre-1940 house with child under 3 resides
Previous poisoning at this house, currently occupied by child under 3
House where child has been poisoned by lead previously
Pre-1978 house where child under 6 years OR a pregnant woman resides
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