The Choose Safe Places for Early Care and Education program reduces children’s risk of being exposed to dangerous chemicals during their care. The harmful exposures could come from chemicals that were improperly cleaned up by a previous building occupant or that are being used by a business next door, chemicals from nearby agricultural practices or hazardous waste sites, or even naturally occurring contaminants like lead or radon. The Department of Health will work with you to evaluate any potential environmental health hazard and will recommend actions to protect children and staff from exposure.

Instructions: This form is to be completed by the child care facility director or responsible person. The Department of Health will use your responses along with a database of known sources of environmental contamination to evaluate your child care facility. We recommend you contact the following people prior to completing the survey, if available: the landlord or former owner of the property; local zoning officer, planning official and/or building inspector; local health department official; and other officials, including tax assessor, town land records, local fire marshal, economic development agency or historical society.

Form ID#: HS01598S

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* 1. Date:

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* 2. Name of child care center

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* 3. What is the physical address of your child care center?

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* 4. Name of responsible person or director (first, last):

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* 5. Current property owner (first, last):

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* 6. At what email address would you like to be contacted?

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* 7. What is your mailing address?

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* 8. What type of child care facility will you/do you have?

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