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 01/11/21
- 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, 62 KB)
- Maintenance Standard - Annual Monitoring Failure (DOC, 18 KB)
- The Maintenance Standard Planning Guide for Required Remediation (PDF, 303 KB)
- 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 01/08/20
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, 278 KB)
- 3977 Inspection of Lodging Establishment (PDF, 107 KB)
- 4007 Food Establishment Inspection Report (PDF, 545 KB)
- 7001 Wild Mushroom Verification Form (PDF, 117 KB)
- Embargo
OSWP Sample Forms, Letters, and Publications - Updated 02/21/20
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, 28 KB)
- Intent to Suspend IP CA (DOC, 29 KB)
- Intent to Suspend OP (DOC, 29 KB)
- 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)
