HE PA VACUUM 
INTAKE QUESTIONNAIRE 
Occupant Address: 
Name:_ Date: 
Address:_ 
Street, City, Zip Code 
Telephone:_ 
Day Time 
Owners Address (If Different): 
Name:_ 
Address:_ 
Street, City, Zip Code 
Telephone:_ Telephone:_ 
Day Time Evening 
Tenant:_(Y/N) . Owner/Occupant:_ 
Age of person Leasing HEPA Vacuum: (Please Check One) 
18-21:_ 22-30:_ 31-45:_ 46-60:_ 61 or Older:_ 
Household Size:_ 
Number of Children 6 and under:_ 
Do any children have a known elevated blood level?_(Y/N) 
Do you know the approximate age/ year of the residence?_ 
Length of time living in residence: Years_Months:_ 
How did you become aware of the program? (Check One) 
Friend/Relative_ Internet_ 
Media (Newspaper, Brochure)_ Other_ 
Community Organization_ 
Telephone:_ 
Evening 
Date: 
Collecting and 
Managing Data on Lead Dust 
4 1 
