Are You and Your Family at risk  
from Lead Poisioning in Your Home ?

Please fill out the information below find out if you and your family may be at risk for lead poisoning. To get more information on a particular question please click on it's link.  The address field is optional, but it would be appreciated if you would provide us with this information because it may help us to pin-point problem area's that may be of risk to our communities.

General Information:

* Name:

   
Neighborhood:

* Address:

City:
State:
Zipcode:
* Email:

Children 6 yrs or Younger living at or frequently visiting this residence:
* Optional Information

Questionnaire (Select Yes or No):

1. Was  the House or Apt building that you living in, built before 1978 ?
2. Has any painting, sanding, or other renovation been done in your home or apt in the past three months ?
3. Have you had doors, windows, woodwork, or furniture restored, refinished, or replaced ?
4. Are there any teeth marks on the surface? Do doors and windows show any signs of wear, impact, or rubbing ?
5. Are there any visable signs of paint chips along the drip line of your  home or under the porch ? 
6. Are there visable signs of flaking paint on or by the painted porch, siding, or other exterior areas ?
7. Are any renovation, painting, or other activities being conducted on neighboring properties ?
8. Do you have imported mini-blinds in your home ?
9. Does the yard by your home have bare soil or areas without grass ?
10. Do you store food or beverages in antique or imported ceramic ware or  leaded crystal ?