Juvenile Facility Health Inspection Report
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JUVENILE FACILITY HEALTH INSPECTION REPORT Juvenile Halls, Special Purpose Juvenile Halls and Camps Health and Safety Code Section 101045 BSCC #: ______
FACILITY NAME: COUNTY:
FACILITY ADDRESS (STREET, CITY, ZIP CODE, TELEPHONE):
CHECK THE FACILITY TYPE AS DEFINED IN JUVENILE HALL: SPECIAL PURPOSE CAMP: TITLE 15, SECTION 1302: JUVENILE HALL: DATE INSPECTED: ENVIRONMENTAL HEALTH EVALUATION
ENVIRONMENTAL HEALTH EVALUATORS (NAME, TITLE, TELEPHONE):
FACILITY STAFF INTERVIEWED (NAME, TITLE, TELEPHONE):
DATE INSPECTED: NUTRITIONAL EVALUATION
NUTRITIONAL EVALUATORS (NAME, TITLE, TELEPHONE):
FACILITY STAFF INTERVIEWED (NAME, TITLE, TELEPHONE):
DATE INSPECTED: MEDICAL/MENTAL HEALTH EVALUATION
MEDICAL/MENTAL HEALTH EVALUATORS (NAME, TITLE, TELEPHONE):
FACILITY STAFF INTERVIEWED (NAME, TITLE, TELEPHONE):
This checklist is to be completed pursuant to the attached instructions.
JUV HEALTH COVER;8/2/12 COVER 1 BSCC FORM 458 (Rev.8/12)