Schools & Childcares Basic Info Form – Philadelphia Water Department

Contact

Name *

Email Address *

Are you the primary contact? *

The primary contact is the person we should contact for questions about your facility and scheduling sampling.

Yes
No

Primary Contact Name *

Primary Contact Email Address *

Location

Name of School or Childcare Facility *

Address *

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

School
Childcare

What is your school’s unique School ID?

Please enter your school’s NCES number or AUN provided by the PA Department of Education if you know it.

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

What is your childcare’s Master Provider ID?

A Master Provider ID (or Master Provider Index) is assigned to childcare facilities by the Pennsylvania Department of Human Serices.

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

Yes
No

What is your childcare’s Master Provider Location ID?

A Master Provider Location ID is assigned to childcare facilities by the Pennsylvania Department of Human Serices.

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

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

What materials are in your facility’s plumbing system for drinking water?

Have any sources of lead been identified at your facility?

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…

Are there any point-of-use (POU) devices, like water filters on faucets or fountains, installed at your facility?

Yes
No
Don’t know

Are there any point-of-entry (POE) devices, like water softeners or filters by the water meter, installed at your facility?

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

Does your facility have a water management plan for regularly flushing water sitting in building plumbing, cleaning aerators, and maintaining filters?

Yes
No
Don’t know

Wrap-Up

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

Do you have any comments, questions, or concerns 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