Test Kit Registration

LeadCare Illinois offers schools and licensed day care homes, group day care homes, and day care centers free lead in water testing.

If your facility has many drinking and cooking water sources, we encourage you to complete a Fixture Inventory before completing the registration form. Use the Fixture Photo Guide to help determine which fixtures need to be sampled as you fill out the Fixture Inventory.

If you have any questions, please call a LeadCare Illinois specialist at 312-300-7074.

IMPORTANT: Has your facility ever registered with any LeadCare Illinois program before? If yes, you do not need to fill out this form again. Simply call us at 312-300-7074 or email us at info@LeadCareIllinois.org. We’ll help you continue with the program.

LeadCare Illinois Registration Form

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Contact Person for the Facility

First Name

Last Name

Phone Number

Email Address

Are you a Spanish Speaker?

Do you represent a School or a Child Care Facility?

Child Care Facility Name

(Please input your facility name exactly as it appears on your DCFS license. If you are in the process of obtaining your license, list your first and last name in this field).

Are you a DCFS-licensed child care facility?

YesNo, but I’m in the process of becoming one

DCFS License Number

School Name

Facility Administrator

School Type

Other

Select the option that applies

Our School Does Not Have An NCES #Our School uses a 7-digit numberOur School uses a 12-digit number

NCES ID

Grades Served From:

Grades Served To:

Facility Address

List the address where the water samples will be collected

Street

City

State

Zip Code

My mailing address is different than the child care facility's address listed above

YesNo

Contact Mailing Address

Street

City

State

Zip Code

Total Number of Children Your Facility Serves

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Does your facility operate out of multiple buildings?
Only select "yes" if you operate out of multiple buildings that are associated with the same license number.

YesNo

How many buildings with separate addresses does your facility operate from?

What year was your home or facility built?
If your facility operates out of multiple buildings, please list the earliest year of construction.

Has your building recently had your water service line replaced? (A water service line connects a home or building to the water main in the street. Some communities are starting to replace these lines if they are made of lead or galvanized material).

Have you previously conducted lead in water testing at your facility?

YesNo

How many times have you tested your water before?

Did LeadCare Illinois conduct the lead in water testing at your facility?

If you previously tested with LeadCare Illinois, please continue to complete this form. A program team member will also follow up with you by phone to collect additional information for your facility.

Please upload a copy of your test results. If you don’t have them on hand right now, email them to us at info@leadcareillinois.org.

Have you already developed and implemented a mitigation plan?

YesNoI’m not sure

Please upload a copy of your mitigation plan. If you don't have it on hand right now, email it to us at info@leadcareillinois.org.

Immediate Mitigation Strategy: Select all that apply

Hold CTRL and Left Click to select multiple options

Other

Long Term Mitigation Strategy: Select all that apply

Hold CTRL and Left Click to select multiple options

Other

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Drinking and Cooking Water Sources

Please indicate the number of cooking and drinking water sources your school facility will need to test. I understand that any missing or incorrect information may delay receiving my test kit.

Kitchen Sinks:

Classroom Sinks:

Restroom Sinks:

Drinking Fountains:

Water Dispensers:

Automatic Ice Makers:

Water Bottle Filling Stations:

Combo Sink and Drinking Fountains:

Combo Drinking Fountain and Water Bottle Filling Stations:

Other Drinking and Cooking Water Sources:

Please describe each “Other drinking water source”:

Please describe each of the 2 “Other drinking water source”

Please describe each of the 3 “Other drinking water source”

Please describe each of the 4 “Other drinking water source”

Please describe each of the 5 “Other drinking water source”

Please describe each of the 6 “Other drinking water source”

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Please describe each of the 11 “Other drinking water source”

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Please describe each of the 12 “Other drinking water source”

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LeadCare Illinois Registration Form

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