Skip to main content
Main navigation
Home
User account menu
Log in
Home
Lead Hazard Reduction Prescreening
You must have JavaScript enabled to use this form.
Current
Section 1
Section 2
Complete
How did you hear about this program?
Someone from the Health Department
Social Media
Social Media network like Facebook, Instagram or other social media
Health Dept. Website
Health Department Website
Connecting Communities in Action/Weatherization
Contractor
Other…
Enter other…
Your Name
First Name
Middle Name
Last Name
Suffix
What is your date of birth
What is your phone number?
What is your email address?
What is your email address?
Confirm your email address
What is your residential address?
Address
Address 2
City/Town
State/Province
New York
Alabama
Alaska
American Samoa
Arizona
Arkansas
Armed Forces (Canada, Europe, Africa, or Middle East)
Armed Forces Americas
Armed Forces Pacific
California
Colorado
Connecticut
Delaware
District of Columbia
Federated States of Micronesia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Marshall Islands
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Palau
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
ZIP/Postal Code
What is your mailing address?
Address
Address 2
City/Town
State/Province
New York
Alabama
Alaska
American Samoa
Arizona
Arkansas
Armed Forces (Canada, Europe, Africa, or Middle East)
Armed Forces Americas
Armed Forces Pacific
California
Colorado
Connecticut
Delaware
District of Columbia
Federated States of Micronesia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Marshall Islands
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Palau
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
ZIP/Postal Code
What is your primary language
- None -
Afrikaans
Amharic
Arabic
Asturian
Azerbaijani
Belarusian
Bulgarian
Bengali
Tibetan
Breton
Bosnian
Catalan
Czech
Welsh
Danish
German
Dzongkha
Greek
English
English, British
Esperanto
Spanish
Estonian
Basque
Persian, Farsi
Finnish
Filipino
Faeroese
French
Frisian, Western
Irish
Scots Gaelic
Galician
Swiss German
Gujarati
Hawaiian
Hebrew
Hindi
Croatian
Haitian Creole
Hungarian
Armenian
Indonesian
Icelandic
Italian
Japanese
Javanese
Georgian
Kazakh
Khmer
Kannada
Korean
Kurdish
Kyrgyz
Lao
Lithuanian
Latvian
Malagasy
Macedonian
Malayalam
Mongolian
Marathi
Bahasa Malaysia
Maltese
Burmese
Nepali
Dutch
Norwegian Bokmål
Norwegian Nynorsk
Occitan
Odia
Ossetian
Punjabi
Polish
Persian, Afghanistan
Pashto
Portuguese, International
Portuguese, Portugal
Portuguese, Brazil
Rohingya
Rumantsch Grischun
Romanian
Russian
Kinyarwanda
Scots
Northern Sami
Sinhala
Slovak
Slovenian
Albanian
Serbian
Swedish
Swahili
Tamil
Tamil, Sri Lanka
Telugu
Thai
Turkish
Tuvan
Uyghur
Ukrainian
Urdu
Vietnamese
Lolspeak
Chinese, Simplified
Chinese, Traditional
Do you want to apply as a homeowner, renter, or landlord?
- Select -
Homeowner
Renter
Landlord
If applying for more than one property address then please complete an additional pre-screen.
Next Page >