Name and address of school:

Principal:

Date of assessment:

Issues to be addressed/assessed

1. School built in in before 1940 1940–1949 1950–1959 1960–1969 1970–1979 1980–1989 1990–1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 ;
   last renovations to school in before 1940 1940–1949 1950–1959 1960–1969 1970–1979 1980–1989 1990–1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
   Description of renovations:

2. Number of portables/portapacs: . Willing to assign a sensitive student to a non-portable/portapac placement? Yes No

3. Heating/Cooling (check all that apply):
   electric gas oil heat pump air-conditioning hot-water radiator other (please specify):

4. Types of flooring used in school (check all that apply):
   terrazzo hardwood vinyl carpeting
   rubber (gym) other (please specify):
   Specify classrooms where carpeting is currently in use:

5. At least two (2) openable windows in all classrooms:
   Yes No
   If no, what percentage of classroms lack windows?
   Window coverings (check all that apply): vertical blinds Venetian blinds drapes other (please specify):
   Lighting (check all that apply): low-harmonic electronic ballast fluorescent full-spectrum fluorescent incandescent other (please specify):

6. Ventilation: heat recovery ventilator (HRV) Yes No
   Direct outdoor exhaust from contaminant sources
   (check all that apply): photocopy machines
   computer labs science labs biology labs
   family studies (stoves, laundry)
   industrial arts (woodwork, metal work, etc.)
   automechanics lab artroom storage/janitorial changerooms swimming pool

7. Are there negative-pressure controls and automatic-closure doors on rooms with contaminant sources? Yes No

8. Are bus bays located away from the building's air intake?
   Yes No
   At what distance? m

9. Is the school located near a powr line corridor/transformer? Yes No
   At what distance? m

10. Are the playgrounds and/or sports fields under/near power lines? Yes No

11. Computers: are low EMF computers or radiation protection screens provided? Yes No

12. Painting: date school last painted
    Types of paints used
    Date designated classroom last painted

13. Has the school building experienced a flood(s) in the past?
    Yes No
    If yes, please specify the year(s)
    and the location of the flood(s)
    Describe the methods used to eliminate molds.

14. Cleaning and maintenance products used
    [please specify and provide Material Safety Data Sheets, as well as samples — please use extra sheet(s)]