Schools & Childcares Basic Info Form – Philadelphia Water Department

Contact

Primary Contact Name *

Email Address *

Location

Name of School or Childcare Facility *

Address *

Is your facility (primarily) a school or childcare? *

School
Childcare

Does the school have more than one physical address (such as multiple branches or buildings)? *

Yes
No

Has this school operated at any other locations or under any other names in the past three years (closure, reopening, merger, move…)?

Yes
No
Don’t know

Is this childcare part of a chain, franchise, or operated by an entity with multiple locations?

Yes
No

What type of building does your childcare operate in?

Does the school/childcare own or lease the building(s) at this location?

Own
Lease
Don’t know

What are your typical operating days?

Include any days when staff are in the building and may use water, even if children are not present.

What are your typical operating hours?

Include any times when staff are in the building and may use water, even if children are not present.

Open

Close

Does your childcare operate during the summer?

Yes
No

Do any programs operate at your school during the summer?

Yes
No
Don’t know

Plumbing

Approximately how many drinking water outlets are in the building(s)?

Include water fountains, bottle filling stations, sinks used for drinking, drink preparation, or food preparation, coffee or ice machines with direct water supply connections, sink/fountain in the nurse’s office…

Does your facility always use cold water for cooking and drinking, including preparing baby formula?

Yes
No
Don’t know

Does your facility regularly flush water sitting in building plumbing overnight or over weekends?

Yes
No
Don’t know

Does your facility clean aerators, also called faucet screens, at least twice a year?

Yes
No
Don’t know

Does your facility use and maintain filters certified to reduce lead?

Yes
No
Don’t know

Has any drinking water testing been done at your facility in the past?

Yes, we have documentation from prior testing
Yes
No
Don’t know

Do you have maintenance, custodial, or plumbing personnel who are familiar with the building’s plumbing and/or construction records?

Yes
No
Don’t know

Was your building (or any of your buildings) built after January 1, 2014, or had complete replacement of all plumbing since then?

Yes
No
Don’t know

Which of the following components are in your facility’s plumbing system?

Wrap-Up

What language(s) are primarily spoken by your staff?

Do you have any comments, questions, or concerns about this process or your drinking water that you would like to share with our team?

May we contact you for research purposes, to help improve this program for other schools and childcares? *

Yes
No

Schedule

Schedule a call with PWD to plan your next steps

The next section will open a pop-up for you to schedule a 20 minute call with PWD for you to get any questions answered and provide us with more information about your facility. If you need to review your answers, do it now. You will not be able to get back to them once you open the scheduler.

In the pop-up, scroll down to select a date and time you are available, (re)enter your name, email, a phone number where you can be reached at that time, and your facility’s name, and click the “Book” button.

Once you have done that, you can close the popup using the X in the top right corner.