2013-2014 ECEAP Site Readiness & Safety

Site Readiness & Health/Safety Survey Instructions

PURPOSE
The purpose of this tool is to assure that your site meets ECEAP Performance Standards. This also offers an opportunity for staff to work together (teaching staff and family support) to complete this survey. As you identify items that need action, this tool will provide you with a list to work from.

COMPLETE SURVEY

1. Make sure you have completed the survey on paper BEFORE the first day of school. If class has already started, please do this ASAP.
2. Enter your data into this survey on the computer by September 30th.

FOLLOW-UP AND QUESTIONS
Coordinators will be following-up on "action plans" as we visit sites/classrooms. Please contact your Health/Nutrition Coordinator if you have any questions.

KEY
* Obtain from your ESD Coordinator
** Created at the Site
(P) Details in PAD

Question Title

* 1. Please identify your Program, Site and Classroom below:

Program Name:

Site Name:

Lead Teacher:

Lead Teacher email:

Lead Teacher phone:

Question Title

* 2. Items POSTED in your classroom:

	Yes	No	N/A
All Hazard Preparedness Plans (earthquake, lockdown, flood etc) by emergency exits.	All Hazard Preparedness Plans (earthquake, lockdown, flood etc) by emergency exits. Yes	All Hazard Preparedness Plans (earthquake, lockdown, flood etc) by emergency exits. No	All Hazard Preparedness Plans (earthquake, lockdown, flood etc) by emergency exits. N/A
All Hazard Preparedness(AHP)/Fire Drills Form. At least 3 AHP different drills are conducted/documented for EACH class during the school year. Fire Drills are monthly for EACH class.	All Hazard Preparedness(AHP)/Fire Drills Form. At least 3 AHP different drills are conducted/documented for EACH class during the school year. Fire Drills are monthly for EACH class. Yes	All Hazard Preparedness(AHP)/Fire Drills Form. At least 3 AHP different drills are conducted/documented for EACH class during the school year. Fire Drills are monthly for EACH class. No	All Hazard Preparedness(AHP)/Fire Drills Form. At least 3 AHP different drills are conducted/documented for EACH class during the school year. Fire Drills are monthly for EACH class. N/A
Animal Care Plans posted by animal and procedures followed	Animal Care Plans posted by animal and procedures followed Yes	Animal Care Plans posted by animal and procedures followed No	Animal Care Plans posted by animal and procedures followed N/A
Child Health Plans and Child Food Plans (posted to maintain confidentiality)	Child Health Plans and Child Food Plans (posted to maintain confidentiality) Yes	Child Health Plans and Child Food Plans (posted to maintain confidentiality) No	Child Health Plans and Child Food Plans (posted to maintain confidentiality) N/A
Classroom Emergency Plan for Accidents and Illnesses	Classroom Emergency Plan for Accidents and Illnesses Yes	Classroom Emergency Plan for Accidents and Illnesses No	Classroom Emergency Plan for Accidents and Illnesses N/A
CPR/First Aid Cards: Current cards for all staff	CPR/First Aid Cards: Current cards for all staff Yes	CPR/First Aid Cards: Current cards for all staff No	CPR/First Aid Cards: Current cards for all staff N/A
Diapering: Procedure is posted and followed when needed.	Diapering: Procedure is posted and followed when needed. Yes	Diapering: Procedure is posted and followed when needed. No	Diapering: Procedure is posted and followed when needed. N/A
Evacuation Map by emergency exits	Evacuation Map by emergency exits Yes	Evacuation Map by emergency exits No	Evacuation Map by emergency exits N/A
Exits are clearly marked with signs and free of clutter	Exits are clearly marked with signs and free of clutter Yes	Exits are clearly marked with signs and free of clutter No	Exits are clearly marked with signs and free of clutter N/A
First Aid Kit Sign: A sign clearly identifying the location of your first aid kit.	First Aid Kit Sign: A sign clearly identifying the location of your first aid kit. Yes	First Aid Kit Sign: A sign clearly identifying the location of your first aid kit. No	First Aid Kit Sign: A sign clearly identifying the location of your first aid kit. N/A
Food Worker Card: Current cards for all staff and volunteers who regularly prepare and/or serve food	Food Worker Card: Current cards for all staff and volunteers who regularly prepare and/or serve food Yes	Food Worker Card: Current cards for all staff and volunteers who regularly prepare and/or serve food No	Food Worker Card: Current cards for all staff and volunteers who regularly prepare and/or serve food N/A
Handwashing reminders (including steps to follow) at child's eye level at handwashing sinks*	Handwashing reminders (including steps to follow) at child's eye level at handwashing sinks* Yes	Handwashing reminders (including steps to follow) at child's eye level at handwashing sinks* No	Handwashing reminders (including steps to follow) at child's eye level at handwashing sinks* N/A
How to Respond Injury and Illness at School (Multi-Colored guide)*	How to Respond Injury and Illness at School (Multi-Colored guide)* Yes	How to Respond Injury and Illness at School (Multi-Colored guide)* No	How to Respond Injury and Illness at School (Multi-Colored guide)* N/A
Medical Conditions/Allergies, Special Diets and Food Preference List: Created by Staff, posted to maintain confidentiality. Post "None" if there are no conditions.	Medical Conditions/Allergies, Special Diets and Food Preference List: Created by Staff, posted to maintain confidentiality. Post "None" if there are no conditions. Yes	Medical Conditions/Allergies, Special Diets and Food Preference List: Created by Staff, posted to maintain confidentiality. Post "None" if there are no conditions. No	Medical Conditions/Allergies, Special Diets and Food Preference List: Created by Staff, posted to maintain confidentiality. Post "None" if there are no conditions. N/A

For any "No" answers, please provide your "action plan" and a date when it will be completed.

Question Title

* 3. Items POSTED for families to easily view and are accessible:

	Yes	No	N/A
And Justice For All poster*	And Justice For All poster* Yes	And Justice For All poster* No	And Justice For All poster* N/A
Child Guidance and Support Policy	Child Guidance and Support Policy Yes	Child Guidance and Support Policy No	Child Guidance and Support Policy N/A
Daily Class Routine (schedule)	Daily Class Routine (schedule) Yes	Daily Class Routine (schedule) No	Daily Class Routine (schedule) N/A
McKinney-Vento Homeless Assistance poster*	McKinney-Vento Homeless Assistance poster* Yes	McKinney-Vento Homeless Assistance poster* No	McKinney-Vento Homeless Assistance poster* N/A
Menus: Current Month's Menus for all meals with corrected changes updated weekly.	Menus: Current Month's Menus for all meals with corrected changes updated weekly. Yes	Menus: Current Month's Menus for all meals with corrected changes updated weekly. No	Menus: Current Month's Menus for all meals with corrected changes updated weekly. N/A
No Food Brought by Families sign* (specific message to ECEAP families--obtain from your H/N Coordinator)	No Food Brought by Families sign* (specific message to ECEAP families--obtain from your H/N Coordinator) Yes	No Food Brought by Families sign* (specific message to ECEAP families--obtain from your H/N Coordinator) No	No Food Brought by Families sign* (specific message to ECEAP families--obtain from your H/N Coordinator) N/A
Parent Bulletin Board	Parent Bulletin Board Yes	Parent Bulletin Board No	Parent Bulletin Board N/A
Policy Council Meeting Minutes & dates of meetings	Policy Council Meeting Minutes & dates of meetings Yes	Policy Council Meeting Minutes & dates of meetings No	Policy Council Meeting Minutes & dates of meetings N/A

For any "No" answers, please provide your "action plan" and a date when it will be completed.

Question Title

* 4. POSTED within reach/view of the phone:

	Yes	No	N/A
Site Information (address, room number, phone number)	Site Information (address, room number, phone number) Yes	Site Information (address, room number, phone number) No	Site Information (address, room number, phone number) N/A
Emergency Phone Numbers (outside line prefix ie 9-911, Poison Control)	Emergency Phone Numbers (outside line prefix ie 9-911, Poison Control) Yes	Emergency Phone Numbers (outside line prefix ie 9-911, Poison Control) No	Emergency Phone Numbers (outside line prefix ie 9-911, Poison Control) N/A

For any "No" answers, please provide your "action plan" and a date by when it will be completed.

Question Title

* 5. Items readily accessible by staff at all times on site:

	Yes	No	N/A
Authorized Persons to Pick Up Child. (Created by program)	Authorized Persons to Pick Up Child. (Created by program) Yes	Authorized Persons to Pick Up Child. (Created by program) No	Authorized Persons to Pick Up Child. (Created by program) N/A
Curriculum Plans	Curriculum Plans Yes	Curriculum Plans No	Curriculum Plans N/A
Daily Attendance/Meal Count Report Forms: Current week best by exit in case of emergency, old reports on file	Daily Attendance/Meal Count Report Forms: Current week best by exit in case of emergency, old reports on file Yes	Daily Attendance/Meal Count Report Forms: Current week best by exit in case of emergency, old reports on file No	Daily Attendance/Meal Count Report Forms: Current week best by exit in case of emergency, old reports on file N/A
ECEAP Performance Standards/Policies (current)	ECEAP Performance Standards/Policies (current) Yes	ECEAP Performance Standards/Policies (current) No	ECEAP Performance Standards/Policies (current) N/A
Family files: Original files maintained in a locked cabinet	Family files: Original files maintained in a locked cabinet Yes	Family files: Original files maintained in a locked cabinet No	Family files: Original files maintained in a locked cabinet N/A
Transportation Child List: List of children riding the bus (bus no./driver names) and/or children being self-transported.	Transportation Child List: List of children riding the bus (bus no./driver names) and/or children being self-transported. Yes	Transportation Child List: List of children riding the bus (bus no./driver names) and/or children being self-transported. No	Transportation Child List: List of children riding the bus (bus no./driver names) and/or children being self-transported. N/A

For any "No" answers, please provide your "action plan" and a date when it will be completed.

Question Title

* 6. Questions for staff:

	Yes	No	N/A
Sufficient ratios of trained staff to children are maintained at all times. 1 adult to 9 children.	Sufficient ratios of trained staff to children are maintained at all times. 1 adult to 9 children. Yes	Sufficient ratios of trained staff to children are maintained at all times. 1 adult to 9 children. No	Sufficient ratios of trained staff to children are maintained at all times. 1 adult to 9 children. N/A
All staff members have a change of clothing in classroom (in the event that clothing is soiled or contaminated).	All staff members have a change of clothing in classroom (in the event that clothing is soiled or contaminated). Yes	All staff members have a change of clothing in classroom (in the event that clothing is soiled or contaminated). No	All staff members have a change of clothing in classroom (in the event that clothing is soiled or contaminated). N/A
All handbags are stored out of children's reach or locked if containing medications. Staff emergency medications can remain unlocked,out of children's reach.	All handbags are stored out of children's reach or locked if containing medications. Staff emergency medications can remain unlocked,out of children's reach. Yes	All handbags are stored out of children's reach or locked if containing medications. Staff emergency medications can remain unlocked,out of children's reach. No	All handbags are stored out of children's reach or locked if containing medications. Staff emergency medications can remain unlocked,out of children's reach. N/A

For any "No" answers, please provide your "action plan" and a date when it will be completed.

Question Title

* 7. General indoor areas:

For any "No" answers, please provide your "action plan" and a date when it will be completed.

Question Title

* 8. Classroom Supplies. Check the following and review the detailed procedures in the PAD (if needed).

	Yes	No	N/A
Arts and craft materials are stored in labeled containers and are non-toxic.	Arts and craft materials are stored in labeled containers and are non-toxic. Yes	Arts and craft materials are stored in labeled containers and are non-toxic. No	Arts and craft materials are stored in labeled containers and are non-toxic. N/A
Chemicals such as soaps, cleaners, disinfectants, pesticides are stored in their original containers and used according to labeled instructions.	Chemicals such as soaps, cleaners, disinfectants, pesticides are stored in their original containers and used according to labeled instructions. Yes	Chemicals such as soaps, cleaners, disinfectants, pesticides are stored in their original containers and used according to labeled instructions. No	Chemicals such as soaps, cleaners, disinfectants, pesticides are stored in their original containers and used according to labeled instructions. N/A
Chemicals are stored away from medications, food/utensils and food preparation areas in a locked (combination or key)cabinet. If stored in the kitchen area, use a lockable cabinet BELOW food or food-contact surfaces to prevent contamination.	Chemicals are stored away from medications, food/utensils and food preparation areas in a locked (combination or key)cabinet. If stored in the kitchen area, use a lockable cabinet BELOW food or food-contact surfaces to prevent contamination. Yes	Chemicals are stored away from medications, food/utensils and food preparation areas in a locked (combination or key)cabinet. If stored in the kitchen area, use a lockable cabinet BELOW food or food-contact surfaces to prevent contamination. No	Chemicals are stored away from medications, food/utensils and food preparation areas in a locked (combination or key)cabinet. If stored in the kitchen area, use a lockable cabinet BELOW food or food-contact surfaces to prevent contamination. N/A
Chemical Sanitizer/Disinfectant: Bleach sanitizer/disinfectant prepared and labeled* according to procedure and tested using test strips*. Sanitizer can remain out of children's reach, Disinfectant must be locked up. Solutions made from chemicals other than bleach must have the appropriate test strips. (Contact your HN Coordinator for assistance).	Chemical Sanitizer/Disinfectant: Bleach sanitizer/disinfectant prepared and labeled* according to procedure and tested using test strips*. Sanitizer can remain out of children's reach, Disinfectant must be locked up. Solutions made from chemicals other than bleach must have the appropriate test strips. (Contact your HN Coordinator for assistance). Yes	Chemical Sanitizer/Disinfectant: Bleach sanitizer/disinfectant prepared and labeled* according to procedure and tested using test strips*. Sanitizer can remain out of children's reach, Disinfectant must be locked up. Solutions made from chemicals other than bleach must have the appropriate test strips. (Contact your HN Coordinator for assistance). No	Chemical Sanitizer/Disinfectant: Bleach sanitizer/disinfectant prepared and labeled* according to procedure and tested using test strips*. Sanitizer can remain out of children's reach, Disinfectant must be locked up. Solutions made from chemicals other than bleach must have the appropriate test strips. (Contact your HN Coordinator for assistance). N/A
Classroom and equipment cleaning schedule/system is in place	Classroom and equipment cleaning schedule/system is in place Yes	Classroom and equipment cleaning schedule/system is in place No	Classroom and equipment cleaning schedule/system is in place N/A
Clothing for children: Ample supply of backup clothing available.	Clothing for children: Ample supply of backup clothing available. Yes	Clothing for children: Ample supply of backup clothing available. No	Clothing for children: Ample supply of backup clothing available. N/A
Drinking water always available for children: Water fountain, cups next to faucet, or cups and pitcher.	Drinking water always available for children: Water fountain, cups next to faucet, or cups and pitcher. Yes	Drinking water always available for children: Water fountain, cups next to faucet, or cups and pitcher. No	Drinking water always available for children: Water fountain, cups next to faucet, or cups and pitcher. N/A
Equipment and toys are child size and age appropriate.	Equipment and toys are child size and age appropriate. Yes	Equipment and toys are child size and age appropriate. No	Equipment and toys are child size and age appropriate. N/A
Furniture is durable and child sized or adapted for children's use.	Furniture is durable and child sized or adapted for children's use. Yes	Furniture is durable and child sized or adapted for children's use. No	Furniture is durable and child sized or adapted for children's use. N/A
Meal utensils (forks, spoons, knives, tongs)* are child sized.	Meal utensils (forks, spoons, knives, tongs)* are child sized. Yes	Meal utensils (forks, spoons, knives, tongs)* are child sized. No	Meal utensils (forks, spoons, knives, tongs)* are child sized. N/A
Medically-rated gloves are readily accessible.	Medically-rated gloves are readily accessible. Yes	Medically-rated gloves are readily accessible. No	Medically-rated gloves are readily accessible. N/A
Toothbrushes, Fluoridated Toothpaste and Holders*	Toothbrushes, Fluoridated Toothpaste and Holders* Yes	Toothbrushes, Fluoridated Toothpaste and Holders* No	Toothbrushes, Fluoridated Toothpaste and Holders* N/A
Toys, materials and equipment are in good condition, and stored in a safe manner.	Toys, materials and equipment are in good condition, and stored in a safe manner. Yes	Toys, materials and equipment are in good condition, and stored in a safe manner. No	Toys, materials and equipment are in good condition, and stored in a safe manner. N/A

For any "No" answers, please provide your "action plan" and a date when it will be completed.

Question Title

* 9. Kitchen, food preparation and storage areas:

	Yes	No	N/A
Dishwasher sanitizes by: reaching 160 degrees indicated by temperature test strips* or use of chemicals.	Dishwasher sanitizes by: reaching 160 degrees indicated by temperature test strips* or use of chemicals. Yes	Dishwasher sanitizes by: reaching 160 degrees indicated by temperature test strips* or use of chemicals. No	Dishwasher sanitizes by: reaching 160 degrees indicated by temperature test strips* or use of chemicals. N/A
Gloves rated for food preparation available for foodservice.	Gloves rated for food preparation available for foodservice. Yes	Gloves rated for food preparation available for foodservice. No	Gloves rated for food preparation available for foodservice. N/A
Storage of Food: labeled, covered and dated when refrigerated, frozen or stored (off floor).	Storage of Food: labeled, covered and dated when refrigerated, frozen or stored (off floor). Yes	Storage of Food: labeled, covered and dated when refrigerated, frozen or stored (off floor). No	Storage of Food: labeled, covered and dated when refrigerated, frozen or stored (off floor). N/A
Thermometers*: Digital Stem Thermometer, Refrigerator and Freezer	Thermometers*: Digital Stem Thermometer, Refrigerator and Freezer Yes	Thermometers*: Digital Stem Thermometer, Refrigerator and Freezer No	Thermometers*: Digital Stem Thermometer, Refrigerator and Freezer N/A

For any "No" answers, please provide your "action plan" and a date when it will be completed.

Question Title

* 10. All Hazard Preparedness. Some items are listed in the "Post in your classroom section."

	Yes	No	N/A
Emergency food and water supplies (minimum 3 days) are available for children and staff.	Emergency food and water supplies (minimum 3 days) are available for children and staff. Yes	Emergency food and water supplies (minimum 3 days) are available for children and staff. No	Emergency food and water supplies (minimum 3 days) are available for children and staff. N/A
Fire extinguishers are certified annually (checked monthly to ensure they have not been discharged). Provide date of last inspection in comment section below.	Fire extinguishers are certified annually (checked monthly to ensure they have not been discharged). Provide date of last inspection in comment section below. Yes	Fire extinguishers are certified annually (checked monthly to ensure they have not been discharged). Provide date of last inspection in comment section below. No	Fire extinguishers are certified annually (checked monthly to ensure they have not been discharged). Provide date of last inspection in comment section below. N/A
Heavy equipment or furniture is anchored and secured from tipping.	Heavy equipment or furniture is anchored and secured from tipping. Yes	Heavy equipment or furniture is anchored and secured from tipping. No	Heavy equipment or furniture is anchored and secured from tipping. N/A
Heavy items stored above a child's height are removed or secured to prevent from falling.	Heavy items stored above a child's height are removed or secured to prevent from falling. Yes	Heavy items stored above a child's height are removed or secured to prevent from falling. No	Heavy items stored above a child's height are removed or secured to prevent from falling. N/A
Smoke detector is in place and checked monthly.	Smoke detector is in place and checked monthly. Yes	Smoke detector is in place and checked monthly. No	Smoke detector is in place and checked monthly. N/A
Supplies specific to a child with special needs are stored for emergency supplies.	Supplies specific to a child with special needs are stored for emergency supplies. Yes	Supplies specific to a child with special needs are stored for emergency supplies. No	Supplies specific to a child with special needs are stored for emergency supplies. N/A
First Aid Supplies and emergency medications are readily portable and taken outside during outdoor play, field trips or whenever the class leaves the classroom.	First Aid Supplies and emergency medications are readily portable and taken outside during outdoor play, field trips or whenever the class leaves the classroom. Yes	First Aid Supplies and emergency medications are readily portable and taken outside during outdoor play, field trips or whenever the class leaves the classroom. No	First Aid Supplies and emergency medications are readily portable and taken outside during outdoor play, field trips or whenever the class leaves the classroom. N/A

Please indicate fire extinguishers last date of inspection. For any "No" answers, please provide your "action plan" and a date when it will be completed.

Question Title

* 11. First Aid Supplies (suggested supplies per class in session). *These items can be requested from the PSESD.

	Yes	No	N/A
Monthly First Aid Kit Inspection Checklist completed.	Monthly First Aid Kit Inspection Checklist completed. Yes	Monthly First Aid Kit Inspection Checklist completed. No	Monthly First Aid Kit Inspection Checklist completed. N/A
Current First Aid Manual* (1)	Current First Aid Manual* (1) Yes	Current First Aid Manual* (1) No	Current First Aid Manual* (1) N/A
Disposable Tweezers*(2)	Disposable Tweezers*(2) Yes	Disposable Tweezers*(2) No	Disposable Tweezers*(2) N/A
Resusci Face Shields*(1)	Resusci Face Shields*(1) Yes	Resusci Face Shields*(1) No	Resusci Face Shields*(1) N/A
Items purchased/provided by site: Gauze squares (40), Scissors (1), Band-Aids of various sizes (1box), Rolled Gauze (1), Triangular Bandage with Safety Pins (1), Non-latex Gloves (4 pairs), Adhesive Tape (1), Compress bandage (6), Flashlight: Fully functioning (1), Extra Batteries,Goggles (1), Ice Packs (1), Paper Cup (4), Plastic Bag (1), Digital Thermometer with Probe Covers, Sealed Bottle of Water (1), Liquid Soap (1), Emergency Medications specific to a child, Child Health Plan, Medication Administration Record, Physician Order for Medications at School, Emergency Contact Phone Numbers for each child, Parent/Guardian Consent for Emergency Treatment	Items purchased/provided by site: Gauze squares (40), Scissors (1), Band-Aids of various sizes (1box), Rolled Gauze (1), Triangular Bandage with Safety Pins (1), Non-latex Gloves (4 pairs), Adhesive Tape (1), Compress bandage (6), Flashlight: Fully functioning (1), Extra Batteries,Goggles (1), Ice Packs (1), Paper Cup (4), Plastic Bag (1), Digital Thermometer with Probe Covers, Sealed Bottle of Water (1), Liquid Soap (1), Emergency Medications specific to a child, Child Health Plan, Medication Administration Record, Physician Order for Medications at School, Emergency Contact Phone Numbers for each child, Parent/Guardian Consent for Emergency Treatment Yes	Items purchased/provided by site: Gauze squares (40), Scissors (1), Band-Aids of various sizes (1box), Rolled Gauze (1), Triangular Bandage with Safety Pins (1), Non-latex Gloves (4 pairs), Adhesive Tape (1), Compress bandage (6), Flashlight: Fully functioning (1), Extra Batteries,Goggles (1), Ice Packs (1), Paper Cup (4), Plastic Bag (1), Digital Thermometer with Probe Covers, Sealed Bottle of Water (1), Liquid Soap (1), Emergency Medications specific to a child, Child Health Plan, Medication Administration Record, Physician Order for Medications at School, Emergency Contact Phone Numbers for each child, Parent/Guardian Consent for Emergency Treatment No	Items purchased/provided by site: Gauze squares (40), Scissors (1), Band-Aids of various sizes (1box), Rolled Gauze (1), Triangular Bandage with Safety Pins (1), Non-latex Gloves (4 pairs), Adhesive Tape (1), Compress bandage (6), Flashlight: Fully functioning (1), Extra Batteries,Goggles (1), Ice Packs (1), Paper Cup (4), Plastic Bag (1), Digital Thermometer with Probe Covers, Sealed Bottle of Water (1), Liquid Soap (1), Emergency Medications specific to a child, Child Health Plan, Medication Administration Record, Physician Order for Medications at School, Emergency Contact Phone Numbers for each child, Parent/Guardian Consent for Emergency Treatment N/A

For any "No" answers, please provide your "action plan" and a date when it will be completed.

Question Title

* 12. Health and Illness Policies:

	Yes	No	N/A
A system is in place to notify families of illness, injuries and communicable disease immediately upon detection.	A system is in place to notify families of illness, injuries and communicable disease immediately upon detection. Yes	A system is in place to notify families of illness, injuries and communicable disease immediately upon detection. No	A system is in place to notify families of illness, injuries and communicable disease immediately upon detection. N/A
A list is available of children whose immunization status is “conditional” or “exempt” and may need to be excluded in case of communicable disease outbreak.	A list is available of children whose immunization status is “conditional” or “exempt” and may need to be excluded in case of communicable disease outbreak. Yes	A list is available of children whose immunization status is “conditional” or “exempt” and may need to be excluded in case of communicable disease outbreak. No	A list is available of children whose immunization status is “conditional” or “exempt” and may need to be excluded in case of communicable disease outbreak. N/A
Ill children are kept in a comfortable area away from others until family arrives (please indicate "where" in the box below).	Ill children are kept in a comfortable area away from others until family arrives (please indicate "where" in the box below). Yes	Ill children are kept in a comfortable area away from others until family arrives (please indicate "where" in the box below). No	Ill children are kept in a comfortable area away from others until family arrives (please indicate "where" in the box below). N/A
Illness/injury forms are completed for all incidents according to Agency/School District procedure.	Illness/injury forms are completed for all incidents according to Agency/School District procedure. Yes	Illness/injury forms are completed for all incidents according to Agency/School District procedure. No	Illness/injury forms are completed for all incidents according to Agency/School District procedure. N/A
Medications are stored in original, labeled containers in a locked cabinet/container with a completed copy of the Child Health Plan (original retained in file), Physician's Orders for Medication at School and an original Medication Administration Record Form (please indicate "where" in the box below)	Medications are stored in original, labeled containers in a locked cabinet/container with a completed copy of the Child Health Plan (original retained in file), Physician's Orders for Medication at School and an original Medication Administration Record Form (please indicate "where" in the box below) Yes	Medications are stored in original, labeled containers in a locked cabinet/container with a completed copy of the Child Health Plan (original retained in file), Physician's Orders for Medication at School and an original Medication Administration Record Form (please indicate "where" in the box below) No	Medications are stored in original, labeled containers in a locked cabinet/container with a completed copy of the Child Health Plan (original retained in file), Physician's Orders for Medication at School and an original Medication Administration Record Form (please indicate "where" in the box below) N/A
Emergency medications (e.g.: inhalers, epi-pens) must be kept readily accessible and out of reach of children with above mentioned documentation.	Emergency medications (e.g.: inhalers, epi-pens) must be kept readily accessible and out of reach of children with above mentioned documentation. Yes	Emergency medications (e.g.: inhalers, epi-pens) must be kept readily accessible and out of reach of children with above mentioned documentation. No	Emergency medications (e.g.: inhalers, epi-pens) must be kept readily accessible and out of reach of children with above mentioned documentation. N/A

Please list below the answers regarding ill children and medications. For any "No" answers, please provide your "action plan" and a date when it will be completed.

Question Title

* 13. Outdoor play area:

	Yes	No	N/A
Daily Playground Check: There is a system in place where an ECEAP staff person(s) check the playground prior to children entering the play area to ensure it is free from dangerous litter, animal waste, broken equipment, and problems with surfacing. (Indicate "who" in the box below)	Daily Playground Check: There is a system in place where an ECEAP staff person(s) check the playground prior to children entering the play area to ensure it is free from dangerous litter, animal waste, broken equipment, and problems with surfacing. (Indicate "who" in the box below) Yes	Daily Playground Check: There is a system in place where an ECEAP staff person(s) check the playground prior to children entering the play area to ensure it is free from dangerous litter, animal waste, broken equipment, and problems with surfacing. (Indicate "who" in the box below) No	Daily Playground Check: There is a system in place where an ECEAP staff person(s) check the playground prior to children entering the play area to ensure it is free from dangerous litter, animal waste, broken equipment, and problems with surfacing. (Indicate "who" in the box below) N/A
Fenced and/or supervision sufficient to prevent children from leaving the premises.	Fenced and/or supervision sufficient to prevent children from leaving the premises. Yes	Fenced and/or supervision sufficient to prevent children from leaving the premises. No	Fenced and/or supervision sufficient to prevent children from leaving the premises. N/A
Garbage is disposed of in a durable, leak proof trash receptacle with a tight-fitting lid.	Garbage is disposed of in a durable, leak proof trash receptacle with a tight-fitting lid. Yes	Garbage is disposed of in a durable, leak proof trash receptacle with a tight-fitting lid. No	Garbage is disposed of in a durable, leak proof trash receptacle with a tight-fitting lid. N/A
Portable equipment, riding toys, helmets are age appropriate, in good condition and safely stored.	Portable equipment, riding toys, helmets are age appropriate, in good condition and safely stored. Yes	Portable equipment, riding toys, helmets are age appropriate, in good condition and safely stored. No	Portable equipment, riding toys, helmets are age appropriate, in good condition and safely stored. N/A
Sandboxes: designed to permit drainage, covered to prevent contamination from cats and animal feces, cleaned of foreign matter, replaced to keep visibly clean. Sand used is labeled as a safe play material or sand that is specifically prepared for sandbox use.	Sandboxes: designed to permit drainage, covered to prevent contamination from cats and animal feces, cleaned of foreign matter, replaced to keep visibly clean. Sand used is labeled as a safe play material or sand that is specifically prepared for sandbox use. Yes	Sandboxes: designed to permit drainage, covered to prevent contamination from cats and animal feces, cleaned of foreign matter, replaced to keep visibly clean. Sand used is labeled as a safe play material or sand that is specifically prepared for sandbox use. No	Sandboxes: designed to permit drainage, covered to prevent contamination from cats and animal feces, cleaned of foreign matter, replaced to keep visibly clean. Sand used is labeled as a safe play material or sand that is specifically prepared for sandbox use. N/A
Spaces are free from harmful animals, insects, pest and poisonous plants.	Spaces are free from harmful animals, insects, pest and poisonous plants. Yes	Spaces are free from harmful animals, insects, pest and poisonous plants. No	Spaces are free from harmful animals, insects, pest and poisonous plants. N/A
Trip hazards including curbing and roots are removed.	Trip hazards including curbing and roots are removed. Yes	Trip hazards including curbing and roots are removed. No	Trip hazards including curbing and roots are removed. N/A

Below, please provide the name of "who" completes the daily playground check. For any "No" answers, please provide your "action plan" and a date when it will be completed.

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* 14. Playground does not include any of the following pieces of equipment: trampolines, swinging gates, giant strides, climbing ropes that are not secured at both ends, heavy metal swings, multiple occupancy swings, ropes swings, or swinging dual exercise rings and trapeze bars. This information comes from the "Public Playground Safety Handbook" and these items are not recommended for public playgrounds. Please call your H/N coordinator if you have questions.

Yes

If playground includes any of this equipment, please provide your "action plan" for removal and completion date.

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* 15. Please describe in detail your system (either within school district or organization) for annually checking playground equipment, including surfacing depth?

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* 16. Additional area for describing issues or plans.

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* 17. Did you keep a paper copy or print a copy (Ctrl + P) of this survey for your records?

Yes

Make sure you click the button at the bottom of the survey to complete and submit. Otherwise, your survey will not be saved.

	Yes	No	N/A
Building is accessible to people with limited mobility including indoor and outdoor environments. (If no, an ADA plan is required.)	Building is accessible to people with limited mobility including indoor and outdoor environments. (If no, an ADA plan is required.) Yes	Building is accessible to people with limited mobility including indoor and outdoor environments. (If no, an ADA plan is required.) No	Building is accessible to people with limited mobility including indoor and outdoor environments. (If no, an ADA plan is required.) N/A
Doors to places that children can enter, such as bathrooms, can be easily opened from the outside.	Doors to places that children can enter, such as bathrooms, can be easily opened from the outside. Yes	Doors to places that children can enter, such as bathrooms, can be easily opened from the outside. No	Doors to places that children can enter, such as bathrooms, can be easily opened from the outside. N/A
Doorways to unsupervised areas are closed and locked unless used for emergency exits.	Doorways to unsupervised areas are closed and locked unless used for emergency exits. Yes	Doorways to unsupervised areas are closed and locked unless used for emergency exits. No	Doorways to unsupervised areas are closed and locked unless used for emergency exits. N/A
Electrical appliances and cords are maintained and out of children's reach, doorways and traffic paths.	Electrical appliances and cords are maintained and out of children's reach, doorways and traffic paths. Yes	Electrical appliances and cords are maintained and out of children's reach, doorways and traffic paths. No	Electrical appliances and cords are maintained and out of children's reach, doorways and traffic paths. N/A
Electrical outlets and power strips must be listed as ‘tamper-resistant’. Plastic plug-type should NOT be used.	Electrical outlets and power strips must be listed as ‘tamper-resistant’. Plastic plug-type should NOT be used. Yes	Electrical outlets and power strips must be listed as ‘tamper-resistant’. Plastic plug-type should NOT be used. No	Electrical outlets and power strips must be listed as ‘tamper-resistant’. Plastic plug-type should NOT be used. N/A
Indoor areas are safe, in good repair, clean and free from hazardous materials.	Indoor areas are safe, in good repair, clean and free from hazardous materials. Yes	Indoor areas are safe, in good repair, clean and free from hazardous materials. No	Indoor areas are safe, in good repair, clean and free from hazardous materials. N/A
Indoor facilities are barrier free for all children and adults.	Indoor facilities are barrier free for all children and adults. Yes	Indoor facilities are barrier free for all children and adults. No	Indoor facilities are barrier free for all children and adults. N/A
Garbage/Trash is stored in a safe/sanitary manner.	Garbage/Trash is stored in a safe/sanitary manner. Yes	Garbage/Trash is stored in a safe/sanitary manner. No	Garbage/Trash is stored in a safe/sanitary manner. N/A
Gas Heat or Appliance: A Carbon Monoxide Detector is used and maintained.	Gas Heat or Appliance: A Carbon Monoxide Detector is used and maintained. Yes	Gas Heat or Appliance: A Carbon Monoxide Detector is used and maintained. No	Gas Heat or Appliance: A Carbon Monoxide Detector is used and maintained. N/A
Gates: Used to prevent children from entering unsupervised areas or stairways are securely anchored, openings small enough to prevent entrapment of a child's head (spaces less than 3.5 inches) and rigid (no accordion-type gates).	Gates: Used to prevent children from entering unsupervised areas or stairways are securely anchored, openings small enough to prevent entrapment of a child's head (spaces less than 3.5 inches) and rigid (no accordion-type gates). Yes	Gates: Used to prevent children from entering unsupervised areas or stairways are securely anchored, openings small enough to prevent entrapment of a child's head (spaces less than 3.5 inches) and rigid (no accordion-type gates). No	Gates: Used to prevent children from entering unsupervised areas or stairways are securely anchored, openings small enough to prevent entrapment of a child's head (spaces less than 3.5 inches) and rigid (no accordion-type gates). N/A
Handwashing sink has liquid soap, paper towels and warm water.	Handwashing sink has liquid soap, paper towels and warm water. Yes	Handwashing sink has liquid soap, paper towels and warm water. No	Handwashing sink has liquid soap, paper towels and warm water. N/A
Handwashing sink is accessible (22-26 inch in height) to children or safety adapted for use.(Slip and moisture resistant platform). Never used for food preparation or cleaning of soiled clothes.	Handwashing sink is accessible (22-26 inch in height) to children or safety adapted for use.(Slip and moisture resistant platform). Never used for food preparation or cleaning of soiled clothes. Yes	Handwashing sink is accessible (22-26 inch in height) to children or safety adapted for use.(Slip and moisture resistant platform). Never used for food preparation or cleaning of soiled clothes. No	Handwashing sink is accessible (22-26 inch in height) to children or safety adapted for use.(Slip and moisture resistant platform). Never used for food preparation or cleaning of soiled clothes. N/A
Heating System: Effective without the use of portable space heaters. Shields used on wall and baseboard heaters to prevent exposure of surfaces that can reach 110 degrees (maintain consistent temperature of 68-75 degrees F)	Heating System: Effective without the use of portable space heaters. Shields used on wall and baseboard heaters to prevent exposure of surfaces that can reach 110 degrees (maintain consistent temperature of 68-75 degrees F) Yes	Heating System: Effective without the use of portable space heaters. Shields used on wall and baseboard heaters to prevent exposure of surfaces that can reach 110 degrees (maintain consistent temperature of 68-75 degrees F) No	Heating System: Effective without the use of portable space heaters. Shields used on wall and baseboard heaters to prevent exposure of surfaces that can reach 110 degrees (maintain consistent temperature of 68-75 degrees F) N/A
Hot Surfaces are out of reach or covered to prevent burns such as pipes,radiators and stoves.	Hot Surfaces are out of reach or covered to prevent burns such as pipes,radiators and stoves. Yes	Hot Surfaces are out of reach or covered to prevent burns such as pipes,radiators and stoves. No	Hot Surfaces are out of reach or covered to prevent burns such as pipes,radiators and stoves. N/A
Hot water temperature at sinks used for handwashing, or where the hot water will be in direct contact with children, should be at a temperature of at least 60°F and not exceeding 120°F.(You can use your food thermometer* to test)	Hot water temperature at sinks used for handwashing, or where the hot water will be in direct contact with children, should be at a temperature of at least 60°F and not exceeding 120°F.(You can use your food thermometer* to test) Yes	Hot water temperature at sinks used for handwashing, or where the hot water will be in direct contact with children, should be at a temperature of at least 60°F and not exceeding 120°F.(You can use your food thermometer* to test) No	Hot water temperature at sinks used for handwashing, or where the hot water will be in direct contact with children, should be at a temperature of at least 60°F and not exceeding 120°F.(You can use your food thermometer* to test) N/A
Lighting sufficient for good visibility in classroom, hallways and stairways.	Lighting sufficient for good visibility in classroom, hallways and stairways. Yes	Lighting sufficient for good visibility in classroom, hallways and stairways. No	Lighting sufficient for good visibility in classroom, hallways and stairways. N/A
Lofts are designed to be age appropriate, safe and well maintained.	Lofts are designed to be age appropriate, safe and well maintained. Yes	Lofts are designed to be age appropriate, safe and well maintained. No	Lofts are designed to be age appropriate, safe and well maintained. N/A
Pesticide Policy and Procedures are followed. Pesticides and lawn chemicals are used in strict compliance with labeling and are used only when children are not present. Pesticide notices posted as required	Pesticide Policy and Procedures are followed. Pesticides and lawn chemicals are used in strict compliance with labeling and are used only when children are not present. Pesticide notices posted as required Yes	Pesticide Policy and Procedures are followed. Pesticides and lawn chemicals are used in strict compliance with labeling and are used only when children are not present. Pesticide notices posted as required No	Pesticide Policy and Procedures are followed. Pesticides and lawn chemicals are used in strict compliance with labeling and are used only when children are not present. Pesticide notices posted as required N/A
Passageways, hallways, stairs and exits are free from obstacles that may obstruct exits routes or cause injury.	Passageways, hallways, stairs and exits are free from obstacles that may obstruct exits routes or cause injury. Yes	Passageways, hallways, stairs and exits are free from obstacles that may obstruct exits routes or cause injury. No	Passageways, hallways, stairs and exits are free from obstacles that may obstruct exits routes or cause injury. N/A
Plants are identified, labeled and are not poisonous.*	Plants are identified, labeled and are not poisonous.* Yes	Plants are identified, labeled and are not poisonous.* No	Plants are identified, labeled and are not poisonous.* N/A
Site is free from drugs, alcohol, violence, guns, demeaning language and behavior.	Site is free from drugs, alcohol, violence, guns, demeaning language and behavior. Yes	Site is free from drugs, alcohol, violence, guns, demeaning language and behavior. No	Site is free from drugs, alcohol, violence, guns, demeaning language and behavior. N/A
Spaces occupied by children are visible and accessible to adults at all times.	Spaces occupied by children are visible and accessible to adults at all times. Yes	Spaces occupied by children are visible and accessible to adults at all times. No	Spaces occupied by children are visible and accessible to adults at all times. N/A
Ventilation is adequate to ensure air quality. (Bathroom/Kitchen with fans or opening windows, air conditioning).	Ventilation is adequate to ensure air quality. (Bathroom/Kitchen with fans or opening windows, air conditioning). Yes	Ventilation is adequate to ensure air quality. (Bathroom/Kitchen with fans or opening windows, air conditioning). No	Ventilation is adequate to ensure air quality. (Bathroom/Kitchen with fans or opening windows, air conditioning). N/A
Walk off mats/non slip surfaces are used on stairways, at entrances and exits to the building and classroom.	Walk off mats/non slip surfaces are used on stairways, at entrances and exits to the building and classroom. Yes	Walk off mats/non slip surfaces are used on stairways, at entrances and exits to the building and classroom. No	Walk off mats/non slip surfaces are used on stairways, at entrances and exits to the building and classroom. N/A
Walls and ceilings have no peeling paint or falling plaster. Free from what may be lead paint or damaged asbestos containing materials (ex popcorn ceilings or water pipe insulation).	Walls and ceilings have no peeling paint or falling plaster. Free from what may be lead paint or damaged asbestos containing materials (ex popcorn ceilings or water pipe insulation). Yes	Walls and ceilings have no peeling paint or falling plaster. Free from what may be lead paint or damaged asbestos containing materials (ex popcorn ceilings or water pipe insulation). No	Walls and ceilings have no peeling paint or falling plaster. Free from what may be lead paint or damaged asbestos containing materials (ex popcorn ceilings or water pipe insulation). N/A
Windows are secured to prevent a child from falling out by installing window guards or limiting the window opening to less than 3½ inches.	Windows are secured to prevent a child from falling out by installing window guards or limiting the window opening to less than 3½ inches. Yes	Windows are secured to prevent a child from falling out by installing window guards or limiting the window opening to less than 3½ inches. No	Windows are secured to prevent a child from falling out by installing window guards or limiting the window opening to less than 3½ inches. N/A
Any window at child height has a decal,picture, or other decoration so children know it is glass and not open space	Any window at child height has a decal,picture, or other decoration so children know it is glass and not open space Yes	Any window at child height has a decal,picture, or other decoration so children know it is glass and not open space No	Any window at child height has a decal,picture, or other decoration so children know it is glass and not open space N/A