Childhood Lead Poisoning Primary Prevention (CLPPP+) Referral Form

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Do you rent or own your property?

RentOwnRent to OwnOther

Landlord Name

First NameLast Name

Landlord Phone #

Please enter a valid phone number.

Are there children under the age of 6 living in the home?

YesNoThere will be (expecting child)

How many children under the age of 6 will be living in the home?

Do you receive or participate in any of the following community resources:

If "other":

Any additional notes or comments you would like to add:

The CLPPP+ program offers free home lead inspections to those living in 14901 and 14904 zip codes.

For more information, contact the lead team at

607-873-1308. Thank you!