Pre-Screening Application Online





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Pre-Screening Application Online

Free Lead Based Paint Assessment

Do you qualify for a FREE lead based paint assessment?

Knoxville Lead Safe and Healthy Homes
PRE-SCREENING APPLICATION
CONTACT PERSON INFORMATION
Name
Street Address
City
Zip Code
Phone #
Secondary Phone # (if available)
INFORMATION ABOUT HOME & CHILDREN
Do you
Own
Rent *
Was the home built before 1978?
Yes
No
Unknown
Does an unborn child or child under the age of 6 live at this address?
Yes
No
Unknown
If a child under the age of 6 lives at this address, what is the child's date of birth/age:
Does a child under the age of 6 visit this address at least 2 different days within the same week, at least 3 hours per visit totaling 6 hours per week, and combined annual visits of 60 hours per year?
Yes
No
Unknown
If a child under the age of 6 visits this address, what is the child's date of birth/age:
NOTE: Child visitation requirements are for owner occupied participants only. Child visitation requirements (the above two questions) are NOT needed for rental properties.
* IF YOU RENT
* If you Rent, provide Landlord's Name:
* If you Rent, provide Address:
* If you Rent, provide Phone Number:
If lead is found during the assessment free lead based paint remediation may be available.
Your online form submission will be sent to CAC Housing & Energy Services.

We also provide a PDF of the form that you can download, fill out, print and then mail to CAC Housing & Energy Services, P.O. Box 1650, Knoxville, TN 37950-1650. Or you can take the printed PDF form to your nearest CAC neighborhood center. Please call 865-244-3080 with any questions.