NYS Department of Health; NYS Education Department, Office of Facilities Planning
First Name _______________________ Last Name _______________________________
Title _________________________________ District Name: __________________________
Yes(1).................... _____.................... If yes, year begun: __________
No but planning to(2).................... _____.................... Year planning to start: _________
No(3).................... _____
Unsure(8).................... _____
Major work: Minor work:
After hours(1) .................... _____.................... _____
During the school day(2) . .................... _____.................... _____
During summer recess, holidays or vacations(3).................... _____.................... _____
Unsure(8) ...... .................... _____.................... _____
Yes(1) _______ No(2) _______ Unsure(9) _______
(check all that apply)
Health & Safety Committee(1)................. ______
Other formal mechanism for responding to complaints(2)................. ______
No formal mechanism in place(3)................. ______
Unsure(8)................. ______
____ Yes, EPA’s Tools for Schools(1)
____ Yes, other IAQ program(2) Please specify program: ______________________________
____ No, but plan to implement program(3)
Please specify program: ______________________________ (go to question 10)
____ No(5) (go to question 10)
____ Unsure(8) (go to question 10)
If yes, year begun: ___________
(8NYCRR155.4d)?................. Yes(1)................. No(2) ................. Unsure(8)
a. There is a district-wide IAQ program........... Yes(1)........... No(2)........... Unsure(8)
If yes, year begun: _________
b. Individual schools have an IAQ program........... Yes(1)........... No(2)........... Unsure(8)
Number of schools with at least one program: _________
a. Named IAQ coordinators?........... Yes(1)........... No(2)........... Unsure(8)
b. Completed walk-throughs of schools?........... Yes(1)........... No(2)........... Unsure(8)
c. Completed ventilation checklists?........... Yes(1)........... No(2)........... Unsure(8)
d. Distributed teacher’s checklists?........... Yes(1)........... No(2)........... Unsure(8)
e. Distributed building maintenance checklists?........... Yes(1)........... No(2)........... Unsure(8)
f. Distributed renovation and repairs checklists?........... Yes(1)........... No(2)........... Unsure(8)
g. Developed an IAQ management plan?........... Yes(1)........... No(2)........... Unsure(8)
a. District has a Health and Safety Committee........... Yes(1)................... No(2)........... Unsure(8)
b. Log is kept of maintenance activities (e.g. filter changes, etc.)........... Yes(1)........... No(2)................... Unsure(8)
c. New carpets are aired out before installation........... Yes(1)........... No(2)................... Unsure(8)
d. Newly painted areas are aired out before re-occupying area........... Yes(1)........... No(2)................... Unsure(8)
e. District uses green-rated cleaning products........... Yes(1)........... No(2)................... Unsure(8)
f. HEPA filters used for cleaning........... Yes(1)........... No(2)................... Unsure(8)
g. Policy exists on animals in classrooms........... Yes(1)........... No(2)................... Unsure(8)
h. Chemical hygiene program is in place........... Yes(1)................... No(2)........... Unsure(8)
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Thank you for the time you spent to complete this survey. Please mail it to:
New York State Department of Health
Center for Environmental Health
547 River Street, Room 200 (School Survey)
Troy, NY 12180