Forms
This page contains links to North Carolina Environmental Health Section forms. To view or print the forms
you may need to download Adobe Reader or an MS Office Viewer.
Childhood Lead Poisoning Prevention Program - Updated 07/05/23
- 3279 Lead Based Paint Investigation
Form (PDF, 318 KB; DOCX, 57
KB)
- 3460 Environmental Investigation for
Lead Hazards (PDF, 123 KB; Fillable PDF)
- 3460P Environmental Investigation for
Lead Hazards (PDF, 192 KB; Fillable PDF) - 07/05/23
- 4116 Lead and
Pregnancy Risk Questionnaire
- 4116S Bilingual
Lead and Pregnancy Risk Questionnaire
- Approval of Extension of Deadline to Complete
Remediation (DOC, 28 KB)
- Chain of Custody Form DHHS 2364
(PDF, 10 KB
) -
12/31/20
- 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)
- 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
- Environmental Health Chain of Custody (non- lead) (PDF, 6 KB)
- Lead Investigation Report Template (DOCX, 63 KB) - 03/08/23
- 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, 33 KB) - 03/13/23
- 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 07/03/23
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)
- 1223 Inspection of Hospital, Nursing Home, Rest Homes, and Other Institutions (PDF, 445 KB)
- 1268 Inspection of
Local Confinement Facility (PDF, 137 KB)
- 1617 Child Care Sanitation Inspection Form - Revised 6/23 (PDF, 164 KB) - 07/03/23
- 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)
