Forms
This page contains links to North Carolina Environmental Health Section forms. To view or print the forms
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Childhood Lead Poisoning Prevention Program - Updated 04/20/22
- 3279 Lead Based Paint Investigation
Form (PDF, 318 KB; DOCX, 57
KB)
- 3460 Environmental Investigation for
Lead Hazards (PDF, 23 KB; Fillable PDF)
- 4116 Lead and
Pregnancy Risk Questionnaire (PDF, 146 KB)
- 4116S Bilingual
Lead and Pregnancy Risk Questionnaire (PDF, 88 KB)
- Approval of Extension of Deadline to Complete
Remediation (DOC, 28 KB)
- Chain of Custody Form (PDF, 6 KB)
- Childhood Lead Poisoning
Prevention Checklist (PDF, 172 KB; DOCX, 36 KB)
- Components of Environmental Lead Investigation Report (DOC, 35 KB; PDF, 20 KB)
- Child Occupied Facility No
Lead Poisoning of Child (PDF, 77 KB; DOCX, 14 KB)
- Child Occupied Facility / Remediation Plan
Required (DOC, 30 KB)
- Child Occupied Facility
/ Submission of Names of Children (DOC, 28 KB) - 01/17/20
- Child Occupied Facility / Submission of
Names of Children- Final Notice (DOC, 29 KB)
- Confirmed Lead Poisoning (Dwelling Owner)
(DOC, 29 KB)
- Confirmed Lead Poisoning (Dwelling
Occupant) (DOC, 28 KB)
- Confirmed Lead
Poisoning (Child Occupied Facility) (DOC, 27 KB) - 01/17/20
- Consent / Refusal Form (PDF, 4 KB)
- DHHS 2364 Environmental Lead Analysis Request Form
(PDF, 10 KB
) -
12/31/20
- EBL at Dwelling (Dwelling Owner) (DOC, 28 KB)
- EBL at Dwelling (Dwelling Occupant) (DOC, 28
KB); Revised 04/2016
- EHS 3651 Evaluation of Child
with Elevated Blood Lead Level (PDF, 27 KB)
- EHS 3958 Lead Risk Assessment
Questionnaire (PDF, 215 KB) - 06/14/21
- Maintenance Standard - Annual
Monitoring Failure (DOC, 18 KB)
- The Maintenance Standard Planning
Guide for Required Remediation (DOCX, 21 KB) - 04/20/22
- Multiple Family Dwelling / Submission of
Names (DOC, 28 KB)
- Multiple Family Dwelling / Request
Submission of Names (parents/ children) (DOC, 29 KB)
- New Owner / Confirmed Lead Poisoning (DOC, 16 KB)
- 02/25/20
- Notice when Dwelling Fails Clearance - Provide
Names (DOC, 29 KB)
- Order To Modify Remediation Plan
(DOC, 14 KB) - 02/25/20
- Owner Lead Paint - No Hazard (DOC, 27 KB)
- Owner Request for Extension (DOC, 29 KB)
- Parent/Day Care - Notice of Lead Poisoning
Hazard (DOC, 29 KB)
- Parent/Day Care Final Notice to Have Child
Tested (DOC, 29 KB)
- PRE-Investigation
Questionnaire for Family Dwellings - COVID-19 (PDF, 122 KB; Fillable
PDF) - 12/29/20
- Remediation Incomplete - Final Notice
(DOC, 28 KB)
- Remediation Not Completed within 60 Days
(DOC, 29 KB)
- Remediation Order After Failure of
Clearance (DOC, 31 KB)
- Remediation Plan Approved (DOC, 28 KB)
- Remediation Plan Not Received - Final
Notice (DOC, 29 KB)
- Remediation Plan Not Submitted within Time Required
(DOC, 29 KB)
- Special Lead Analysis of Drinking Water Request and Chain of Custody Record (DHHS 4122) - for
Local Health Department use; LHDs please contact your Regional Environmental Health
Specialist within the Childhood Lead Poisoning Prevention
Program.
- Spice and Home Remedy Survey
(PDF, 149 KB Fillable
PDF); Spanish Version:
Encuesta sobre especias y remedios caseros (PDF, 149 KB Fillable PDF) - 01/11/21
- Verification of Lead Poisoning Hazard
Remediation (DOC, 28 KB)
- Verification of School-Based
Center (DOC, 14 KB) - 02/25/20
Elevated Lead in Water At Child Care Centers .2816
Food Protection and Facilities Branch - Updated 04/05/22
Some branch forms have been moved to a separate content area.
- 1026 Handwashing Sign (English and Spanish)
(PDF, 306 KB)
- 1050 Inspection of Summer Camp
(PDF, 256 KB)
- 1163 Inspection of School (PDF, 107
KB)
- 1213 Inspection of Hospital, Nursing
Home, Rest Homes, and Other Institutions (PDF, 246 KB)
- 1268 Inspection of
Local Confinement Facility (PDF, 137 KB)
- 1617 Child Care Sanitation
Inspection Form - Revised 9/19 (PDF, 830 KB) - 01/08/20
- 2094 Inspection of
Residential Care Facility (PDF, 155 KB)
- 3601 Inspection of Resident
Camp (PDF, 486 KB)
- 3960 Inspection of Swimming Pool (PDF, 327
KB) - 04/05/22
- 3977 Inspection of Lodging
Establishment (PDF, 107 KB)
- 4007 Food
Establishment Inspection Report (PDF, 2.22 MB) NEW 10/01/21
- 7001 Wild Mushroom
Verification Form (PDF, 117 KB)
- Embargo
OSWP Sample Forms, Letters, and Publications - Updated 01/05/22
Maintenance and Inspection Forms
Generic Forms/Permits
- Application Template for IP CA
(DOC, 34 KB)
- Complaint, Repairs, and NOV Tracking
Sheet (XLS, 72 KB)
- Denial Letter (DOC, 27 KB) - 07/05/22
- Intent to Suspend IP CA (DOC, 28 KB) - 07/05/22
- Intent to Suspend OP (DOC, 28 KB) - 07/05/22
- IP CA Template (DOC, 34 KB)
- North Carolina Distribution Encroachment Agreement for Nitrification Field Encroachments
- 02/21/20
- Notice of Violation (DOC, 24 KB)
- Operation Permit Inspection
Checklist (DOC, 420 KB)
- Operation Permit Template (DOCX, 31
KB)
- Records
Retention Schedule for Health Departments
- Request or Decline Revised AC
(DOCX, 55 KB)
- Sample Maintenance and Inspection
Agreement (PDF, 16 KB)
- Site Plan Worksheet (DOC, 30 KB)
- Site Sketch IP CA (DOC, 30 KB)
- Soil and Site Evaluation
Worksheet (DOC, 150 KB)
- Voluntary
Relinquishment of Administrative Appeal Rights (DOCX, 55 KB)
