Environmental Issues Referral Form for Inspections of Day Care Centers and Group Day Care Homes
Name of Daycare Center ________________________________________________________________
Name of Inspector ____________________________________ Date of Inspection __________________
Address of Daycare Center ______________________________________________________________
Instructions: If item is observed, check applicable box. Space is provided at the end of the form for any additional information you think would be helpful. Taking a photograph or making a simple sketch can be helpful. You do not need to complete this form if no items are observed.
- Outdoor PropertyThe following items are visible at the property where the daycare center is located.___ Metal Drums or Barrels___ Old car/vehicle parts___ Discarded White Goods (i.e., old appliances)___ Construction and Demolition debris pile (e.g., bricks/concrete, wood, plaster/drywall, plumbing fixtures, roofing, glass, electrical wiring, piping, asphalt pavement, insulation).___ Barn(s), farm machinery/equipment
- Daycare Building(s)The following are visible at the building within which the daycare center operates.___ Loading dock, large delivery doors___ Old Mill Building/Mill Complex___ Old brick construction, resembles old factory building___ Resembles funeral home
- Adjacent BusinessesThe following businesses are operating immediately adjacent to the child care center, and within the same building or building complex as the child care center. For example, if a child care center is located next door to a dry cleaner but the dry cleaner is in a separate building, do not check the box. If a daycare center is located within the same strip mall building complex as a nail salon/hair salon, but the nail salon is several (or more) doors away from the daycare center, do not check the box. However, if a child care center is next door to a nail salon/hair salon and within the same strip mall building, check the nail salon box.___ Dry Cleaner___ Nail Salon/Hair Salon___ Auto Repair/Auto Painting Shop___ Copy/Print Shop
For Office Use Only |
Referred to Inspector Date: ______________ Ref. by:_________________ Rec’d by:_________________ |
Inspector Follow-up Complete Date: _______________________________ |
Follow-up comments: _______________________________________________________________________________________________________________ |
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Page last reviewed: October 30, 2018
Content source: Agency for Toxic Substances and Disease Registry