Registration Form: Lead and Copper Mail-In Testing Program for Drinking Water at Child Care and Early Learning Sites Survey

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Thank you for your interest in the Washington State Department of Health’s (DOH) free mail-in testing program for lead and copper in drinking water at child care and early learning sites in Washington.

This program is funded by the Environmental Protection Agency (EPA) through the Water Infrastructure Improvements for the Nation Act (WIIN). If lead or copper is detected in your drinking water, we will work with you to identify resources to get it fixed.

Participants will be sent everything they need to collect and mail their water samples to our lab for testing. We ONLY need to test water outlets that are used for cooking, drinking, or preparing formula. If you are ready for testing and would like to be mailed water sampling supplies, please complete the registration form below. After you submit the form, program staff will contact you about next steps within three business days. Test results take about three weeks once the lab receives your samples and they will be e-mailed to you. Results will also be posted to this webpage quarterly.

If you need help filling out this form or would like more information before signing up for testing, please contact us at leadfreekids@doh.wa.gov or 564-669-1098.

Information collected via this survey may be subject to release in accordance with RCW 42.56 (Public Records Act).

1.Child Care/Early Learning Program Name: (Put your name here if you do not yet know the name of your site)(Required.)

2.Contact information:(Required.)

First and last name:

Phone Number:

Email Address:

3.Physical address to ship supplies to: (No PO Boxes)(Required.)

Street Address

City

Zip code

County

If your shipping address is different than the address of your child care site, list your child care address here:

4.Is this child care or early learning site associated with a Native American tribal nation?(Required.)

Yes

Prefer not to say

5.I am seeking testing because:(Required.)

I am getting licensed for the first time.

My water test is expiring (please list DCYF provider number below).

Other

Provider Number:

6.We have water collection and shipping instructions available in English, Spanish, Somali, traditional Chinese and simplified Chinese. I need to schedule a call with an interpreter to go over instructions in another language:(Required.)

Yes (A staff member will reach out to schedule a call with an interpreter)

Specify language:

7.Does your child care program serve children age six or under?

Yes

Not sure

8.Does your child care program receive any subsidies?

Yes

Not sure

9.Does your site receive Head Start funding?(Required.)

Yes

Not sure

10.Number of children your child care program is licensed to serve:(Required.)

11.We only need to test water outlets that are used for COOKING, DRINKING, or PREPARING FORMULA. How many taps do you use for drinking, cooking, or preparing formula? Please give an exact number so we can send you the correct number of sample bottles.(Required.)