Schools & Childcares Facility Intake Form

This form is for participation in the PWD Schools & Childcares Lead Sampling Program.

Items marked with an asterisk (*) are required fields. If you have any questions, or to fill out the survey over the phone, please call (215) 685-1407.

Estimated time to complete: 5-10 minutes

Email for non-humans

Contact

Contact Previous Next

Primary Contact Name *

Email Address *

Phone Number *

Location

Location Previous Next

Name of School or Childcare Facility *

Address *

Address Line 2

City *

State *

ZIP Code *

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?

– Select –Storefront/Dedicated FacilitySchoolCommunity CenterChurchHomeOther

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.

• Monday
• Tuesday
• Wednesday
• Thursday
• Friday
• Saturday
• Sunday

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

Plumbing Previous Next

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?

• Lead service line
• Galvanized service line
• Lead solder
• Brass installed before 1986
• Brass installed between 1986 and 2014
• None of the above
• Don’t Know
• Add new choice

Wrap-Up

Wrap-Up Previous Next

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

Submit