| Do you live in a |
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Are you on city water supply? |
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| Do you know the hottest temperature of the water in your pipes? (Maximum 120 degrees) |
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Do you have a swimming pool or hot tub? |
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| Is there a working smoke alarm on each floor of your house? |
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Do you and your children always use a carseat / seatbelt when riding in a car? |
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| Are there smokers in your household? |
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| Will your child live in or regularly visit a house with peeling or chipped paint built before 1967? |
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Will your child live in or regularly visit a house built before 1960
with recent, ongoing or planned renovation or remodeling? |
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| Does your home include any person being followed or treated for lead poisoning? |
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Is there an adult in the household who works with lead in either a job or hobby? (Example: soldering, auto body repair, batteries) |
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| Do you live near an active lead smelter, battery recycling plant, or other industry likely to release lead? |
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Are there pets in your household?
If yes, what kind? |
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| Are there firearms in your home? |
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Is alcohol consumed in your home? |
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| Are they loaded? |
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| Are they locked? |
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| Are there regular medications or illegal drugs used in your home? |
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Has anyone caused you or your spouse physical or sexual harm? |
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| Do you plan to use child care? |
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Daycare? |
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| Group care with sitter? |
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Home care with sitter/nanny? |
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| Is there any other information that we should know to care for your child? |
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