GenLog - Detail page

KY Agencies \| KY Services Jump to Page Content. Secondary Menu About CHFS \| Contact Us \| Forms and Documents
Jump to Page Content. Home Entry New Entry	Page Content Kentucky Radon Test Request Form Logging Instructions Fill out and submit this form to receive a Radon Test Kit (laboratory analysis included). This test is easy to perform and the results will be sent directly to you. Only one kit allowed per household Requester Detail Entry Section Type of Request: Required Field Type of Testing: Required Field First Name: Required Field Last Name: Required Field Please enter the street address/location for radon kit below. Address: Required Field Address: If you need the test mailed to a P.O. Box, please provide the number in addition to your home address. P.O. Box: City: Required Field State: Required Field Zip Code: Required Field County: Required Field Email: Required Field Invalid entry format Phone: Required Field Invalid entry format How did you hear about program Required Field Comments: Exceeding 2000 characters What floor will be tested? Required Field Comments: Exceeding 1000 characters Type of Building? Required Field Comments: Exceeding 1000 characters Where will you place your kit? *Required Field Comments: Exceeding 1000 characters Admin Section This section is for administrative use only. Please do not fill in any fields. Status: Pending Referred to Grant Participant Test Sent Grant Participants: Date Sent or Referred: Invalid entry format Comments: Exceeding 5000 characters Jump to Site Menu
Contact Us \| CHFS Site Map Privacy \| Disclaimer \| Individuals with Disabilities Copyright © 2009 Commonwealth of Kentucky All rights reserved.