Facility Nomination Form

Lead Testing in Schools and Child Care Facilities Drinking Water (LWSC) Program Facility Nomination Form

Type of Facility(Required)

Facility Name

Select District and School name

Facility Address

Street Address City ZIP / Postal Code

Which of the following best describes you?(Required)

Parent / Guardian of child at facility

Concerned member of the community

Public water system representative

Staff member at facility (not Director / Superintendent / Principal)

Other