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Cover Sheet for Example Documentation

Please complete the following form and submit along with your documentation. If you have any questions, please email us at [email protected].

The following documentation has been submitted to ASTHO for the Accreditation Library as a potential example of Health Department documentation that might meet the PHAB Domain 6 Standard 3 Measure 2.

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Document Asbestos Log of Inspection Reports Title: Document 2012 Date: Version of Standards and Measures Used: 1.5 Related PHAB Standard and Measure Number Domain: 6 Standard: 3 Measure: 2 Required 2 Documentation: Short description of how this document meets the Standard and Measure’s requirements:

This example is example is a screen shot of the Excel workbook used by the Asbestos Program to log and track inspections of schools, along with print‐outs of data from two tabs of that workbook. PDF pages 2 ‐ 9 are excerpts from the larger workbook that logs inspection reports. The first tab, demonstrated in pdf page 2‐3, provides tracking information, such as soon name, location, and size, and the type of enforcement action (actions taken), if any, that occurred following the inspection. The second tab, pdf pg 4 ‐ 9 provides the current status, return inspections, and final disposition of an expectation. The date of the notice of non‐compliance is tracked in the send tab of the workbook as well (pdf page 4 ‐ 9). Submitting Connecticut Department of Public Health Agency: Staff Contact Melissa Touma Name: Staff Contact Accreditation Coordinator Position: Staff Contact Email: [email protected] Staff Contact 860 509 7179 Phone:

Grant NAIS/EPA # of Final Report Count LEA Inspection Date School Name Address Type Grant Qtr Objective Students Date Comments Enf Action? Date of NON Date of LEA Response Date of DPH review Date of Resolution ICIS ICIS(EPA Program ID) Count Neutral, Never Inspected, late Wethersfield 6/1/12 Charles Wright Elementary 186 Nott Street Public 1 3 yr reins 302 06/12/12 Complaint NON 7/9/12 112

EJAGI, past Domus 6/8/12 Stamford Academy 229 North Street, Stamford Charter 1 noncompliance 130 09/10/12 not in compliance NON 2/7/13 172

EJAGI, past Domus 6/8/12 Trailblazers Academy 83 Lockwood Avenue, StamforCharter 1 noncompliance 133 09/10/12 not in compliance NON 2/7/13 177

Vernon 6/13/12 Rockville High School 70 Loveland Hill Road Public 1 Neutral, >6 1,227 09/11/12 not in compliance NON 9/11/12 162

Ethel Walker 6/26/12 Ethel Walker 230 Bush Hill Road, Simsbury Private 1 Neutral, >6 400 01/24/13 not in compliance NON 1/24/13 159 Neutral, Never Inspected, No EastConn 6/28/12 Quinebaug Valley Middle College 742 Upper Maple Road Public 1 AMP 127 10/01/12 not in compliance NON 5/3/13 161

Bristol 7/11/12 Memorial Boulevard Memorial Boulevard Public 1 EJAGI 544 12/10/12 In Compliance Compliant 12/10/12 142

Bristol 7/11/12 O'Connell 120 Park St Public 1 EJAGI 364 01/25/13 In Compliance Compliant 1/25/13 157

Miss Porter's 7/18/12 Miss Porter's School 60 Main Street, Farmington, C Private 1 Neutral, >6 11/30/12 not in compliance NON 11/30/12 144

Brookfield 8/15/12 Brookfield High School 45 Long Meadow Hill Road Public 1 Neutral, >6 929 08/15/12 In compliance Compliant 5/29/13 107

Middletown 8/22/12 Macdonough Elementary School 66 Spring Street, Middletown, Public 1 Neutral, >6 270 02/26/13 not in compliance NON 2/6/13 139 Neutral, incomplete Stamford 9/5/12 Dolan Middle School 51 Toms Road Public 2 2010 AHERA 641 02/28/13 not in compliance NON 3/19/13 117

Christian Heritage >6, no 3 yr School 10/3/12 Christian Heritage School 575 White Plains Road TrumbuPrivate 2 since 2002 440 01/25/13 not in compliance NON 1/25/13 113

Complaint, >6, Putnam 10/11/12 Putnam High School 152 Woodstock Ave Public 2 EJ, no 3 yr 317 12/03/12 not in compliance NON 12/3/12 160 EJAGI, new Hartford Area 7th building in 99, Day Adventists 10/12/12 Hartford Area Seventh Day Adventist Sc474, Woodland Street, HartfordPric 2 no plan 60 11/06/12 not in compliance NON 11/6/12 128 >6, name change w/our Carmel Academy 10/17/12 Carmel Academy 270 Lake Avenue, Greenwich, Private 2 submittal. 2 225 10/07/14 not in compliance tbd NON 10/7/14 108 Greenwich Japanese Day School 10/17/12 Greenwich Japanese Day School-unann270 Lake Avenue, Greenwich, Private 2 Neutral, >6 225 NON FOLLOW UP 2/23/15 126

Windham Public Schools 11/1/12 Windham High School 355 High Street, Willimantic, CPublic 2 Complaint, EJ 1,012 04/25/13 mostly in complianceNON 4/25/13 179

Explorations Charter 12/5/12 Explorations Charter School 71 Spencer Street, Winsted, C Private 3 EJAGI, >6 85 04/25/13 minor violations NON 4/25/13 124 EJAGI, Hartford Public complaint, Schools 12/6/12 Simpson Waverly 55 Waverly St Public 3 follow up 443 01/21/13 violations NON 12/28/12 168 Hans Christian Anderson Neutral, >6, No Montessori 12/14/12 Hans Christian Anderson Montessori 212 Bolton Center Road Private 3 plan on file 27 01/25/13 no plan NON 1/25/13 127

RSD 16 12/19/12 RSD 16-Algonquin Elementary School 12 Center Street, Prospect Public 3 >6, Neutral 517 03/07/13 not in compliance NON 3/7/13 164

RSD 16 12/19/12 RSD 16-Community School 30 Coer Road, Prospect Public 3 >6 Neutral 232 11/05/13 not in compliance- abNON 11/5/13 166

ACES (RESC) 1/18/13 ACES-Village School 31 Temple Street, North HavenPublic 3 >6, Neutral 174 04/25/13 In Compliance NON 4/25/13 99

ACES (RESC) 1/18/13 ACES-Mill Road Elementary 295 Mill Road, North Haven Public 3 >6, Neutral 193 04/26/13 In Compliance NON 4/26/13 98

Pomfret School 1/23/13 Pomfret School 398 Pomfret Road Private 3 >6 Neutral 355 05/03/13 minor violations-recoNON 5/3/13 123

Hartford 1/24/13 Breakthrough II Magnet 395 Lyme Street Public 3 >6, EJ 282 08/19/14 Not in compliance NON 3/17/14 106 Center Of Progressive Private- Education 3/1/13 Center Of Progressive Education 425 Grant Street, Bridgeport SPED 4 EJAGI, >6 2 05/14/13 Not in compliance NON 5/14/13 110

New Hartford 3/15/13 Ann Antolini School 30 Antolini Road, New HartfordPublic 4 >6, Neutral 347 05/13/13 Not in compliance NON 5/13/13 103

New Hartford 3/15/13 New Hartford Elementary School 40 Wickett Street, New Hartfor Public 4 >6, Neutral 123 05/13/13 Not in compliance NON 5/13/13 152

Monroe 4/5/13 Alternative High School 838 Main St, Monroe Public 4 >6, Neutral 20 05/14/13 Minor Violations NON 5/14/13 102

Monroe 4/5/13 Stepney Elementary School 180 Old Newtown Rd, Monroe Public 4 >6, Neutral 505 06/27/13 Minor Violations NON 6/27/13 174

>6, Neutral; East Hartford 4/12/13 New Testament Baptist School-Unanno111 Ash Street, East Hartford Private 4 EJAGI 159 07/25/13 mostly in complianceNON 7/25/13 154

Thompson 4/16/13 Marianapolis Preparatory School 25 Chase Road, Thompson Private 4 >6, Neutral 377 05/21/13 not in compliance NON 5/21/13 141 >6, past non- complaince: New Britain 4/26/13 St. Matthew's School-Unannounced 99 Franklin Square New BritainPrivate 4 EJAGI 40 07/25/13 Not in complaince FOLLOW UP 7/25/13 170 >6, past non- complaince, no Ledyard 4/30/13 Ledyard High School 24 Gallup Hill Rd Public 4 3 yr rein report 928 07/26/13 Not in compliance tbd NON 7/26/13 136

>6, missing 12' Cornwall 5/3/13 Cornwall Consolidated School-Unannounced RSD 1 Public 4 3-year 102 08/09/13 Not in compliance NON 8/9/13 115

Litchfield 5/10/13 Center School Public 4 >6 287 10/30/13 mostly in complianceNON 10/30/13 111

Litchfield 5/10/13 Intermediate School Public 4 >6 254 10/30/13 mostly in complianceNON 10/30/13 133

No plan on site- Waterbury 5/15/13 Alpha & Omega Christian Academy-Una50 Linden Street, Waterbury, CPrivate 4 EJAGI 24 05/16/13 Not in compliance NON 5/16/13 101

No plan on Waterbury 5/23/13 Yeshiva K'Tana- Unannounced 32 Hillside Street, Waterbury, CPrivate 4 site; EJAGI 315 08/21/13 Not in compliance NON 7/9/13 181

No plan on Waterbury 5/23/13 Yeshiva Gedolah-Unannounced 359 Cook Street, Waterbury, CPrivate 4 site; EJAGI 120 08/21/13 Not in compliance NON 7/23/13 180

Berlin-Kensington 6/5/13 Moreland Hill-Unannounced 166 Lincoln Street, Berlin, CT 0Private 1 >6, Neutral 55 12/11/13 Not in compliance NON 9/25/13 147

>6, Neutral; Hartford 6/12/13 Watkinson School 180 Bloomfield Avenue, HartfoPrivate 1 EJAGI 250 09/17/13 Mostly in complianceNON 9/17/14 178

Woodbridge 6/19/13 Jewish High School of Connecticut 360 Amity Road, Woodbrige, CPrivate 1 >6, Neutral 37 12/16/14 Not in compliance FOLLOW UP 12/16/14 134 No plan on site- Never been NON/AMP Meriden 7/3/13 Connecticut Christian Academy-Unanno601 Paddock Avenue, MeridenPrivate 1 inspected; 25 09/18/13 Not in compliance approved 9/18/14 114

Manchester 7/17/13 East Catholic 115 New State Road, ManchesPrivate 1 Complaint, >6 684 02/03/14 Not in compliance NON 2/3/14 120

Berlin 7/30/13 St Paul School 461 Alling Street, Berlin, CT 06Private 1 Complaint, >6 239 10/07/13 Not in compliance NON 10/7/13 169

Never been NON/AMP Niantic 8/6/13 Lighthouse Voc-ED-School 58 Pennsylvania Avenue, NianPrivate 1 inspected 10 10/03/13 Not in complinace-Eaapproved 10/3/2013-No plan 137

Never been Manchester 8/7/13 Community Child Guidance School 317 N. Main Street, ManchestePrivate 1 inspected 42 10/02/13 Not in compliance-M NON 10/2/13 173

Plainville 8/9/13 Northwest School (The Wheeler Clinic 91 Northwest Dr Private 1 tip/Bill S. 212 08/26/13 Not in compliance NON 8/26/13 156

Never been NON/AMP Niantic 8/16/13 Lighthouse Voc-ED-School 312 Main Street, Niantic, CT 0 Private 1 inspected 10 10/03/13 Not in complinace-Eaapproved 10/3/2013-No plan 138

Never been NON, plan Windsor 9/6/13 Madina Academy-unnanounced 519 Palisado Avenue, Windso Private 2 inspected 140 NO PLAN Not in compliance submitted NON - no plan 140

>6, tip, public Trumbull Public 2 activity 450 03/20/14 NON 3/20/14 9/11/13 Middlebrook Elementary School 220 Middlebrook Avenue, Trum EJAGI Past Not in compliance 143 noncompliance Hartford 10/18/13 Achievement First-Hartford Academy 305 Greenfield Street Public 2 Follow-up 1,000 08/19/14 Not in compliance NON 8/19/14 100

EJAGI-Never Hartford 10/25/13 Eagle House Educational Program 1680 Albany Avenue, Hartford Private 2 been inspected 14 08/19/14 Not in compliance-(reNON 11/12/13 119

Wethersfield 11/8/13 Emerson Williams School 461 Wells Road, Wethersfield, Public 2 Complaint, >6 478 11/07/13 No plan on file(in the NON No Plan NON only 122 EJAGI-Never been inspected- Bridgeport 11/20/13 Fairchild Wheeler Inter-District Magnet S840 Old Town Road, Bridgepo Public 2 Newly opened 870 12/06/13 Not in compliance(re NON 8/19/14 125

Plymouth 11/22/13 Plymouth Center School 104 North Street, Plymouth, CTPublic 2 >6 350 08/19/14 Not in complaince NON 3/5/15 158

West Hartford 12/5/13 Intensive Education Academy 840 North Main Street Private 3 >6 56 8/19/14 131 K991304160‐CT AHERA JFB Notices of Noncompliance Issued by DPH (Aug 2009 through May 2012)

LEA Date NON Rec’v certified Due LEA Response Review completed Closed or Initials &Date Refer Closed-out Comments 2 Adelbrook (Children's Home of Cromwell), Cromwell 6/1/2012 45 days 7/12/2012 emailed most 10/25/2013

Hartford_Jumoke 6/29/2012 7/3/2012 45 days responded 4/5/2013 Closed KD -4/5/2013

Wallingford, Heritage Baptist School 6/29/2012 7/5/2012 45 days 10/25/2013 2/7/2014 Bridgeport Public Schools- The Learning Center 7/16/2012 7/19/2012 45 days 8/30/2012 3 yr reinsp submitted Waterbury_Chase Collegiate 9/7/2012 9/17/2012 45 days responded

Wethersfield-Charles Wright 9/7/2012 9/13/2012 45 days 10/24/2012 10/25/2012 Closed KD 10/25/12

Vernon- Rockville High School 9/25/2012 9/26/2012 45 days Closed KD- 1/10/2013

Middletown Public Schools 11/26/2012 11/29/2012 45 days Closed KD- 3/21/2013

Killingly_EastConn- QVC Middle College 12/11/2012 12/14/2012 45 days 12/24/2012 4/8/2013 Closed KD- 4/15/13

Putnam Public Schools 12/13/2012 12/14/2012 45 days Closed KD-11/26/2013

Farmington_Miss Porter's School 12/18/2012 12/21/2012 45 days 3/4/2013 3/22/2013 Closed 7/6/2013 KD

The Ethel Walker School, Simsbury 1/25/2013 1/28/2013 60 days responded 3/12/2013 Closed 4/11/2013 KD

Trumbull, Christian Heritage School 1/29/2013 2/1/2013 45 days responded 4/11/2013 Closed 4/11/2013 KD

Hartford SDA 3/5/2013 3/11/2013 45 days K991304160‐CT AHERA JFB Notices of Noncompliance Issued by DPH (Aug 2009 through May 2012)

RSD 16 (Algonquin & Community Sch) Domus/Stamford 3/21/2013 3/27/2013 45 days 4/29/2013 6/27/2013 Closed 6/27/13 KD Acad/Trailblazers Acad 4/2/2013 4/11/2013 45 days

Explorations Charter School, Winsted 4/30/2013 5/3/2013 45 days 10/3/2013

Stamford Dolan School 5/14/2013 5/20/2013 45 days 5/24/2013

Pomfret School 5/22/2013 5/25/2013 45 days 6/21/2013 1/26/2015 Closed KD- 6/23/2015

Hartford Simpson Waverly 5/23/2013 5/29/2013 45 days Glastonbury Public Schools (Hopewell) 6/14/2013 6/20/2013 45 days

Windham Public Schools (HS) 6/14/2013 6/20/2013 45 days Thompson, Marianapolis 6/24/13 6/24/2013 6/26/2013 45 days 1/7/2015 Incomplete

Bridgeport, COPE (APT Foundation) 6/27/2013 7/1/2013 45 days 7/24/2014 7/24/2014 closed 7/24/2013 KD

9/3/13 rev to Monroe Stepney_Alt HS 7/16/2013 7/18/2013 45 days 8/8/2014 2/10/14 incomplete East Hartford_New Testament 7/30/2013 45 days 8/30/2013 10/18/2013 closed 10/18/2013 KD

New Harford Public Schools 7/30/2013 45 days ACES -Village & Mill Schools 8/21/2013 45 days 10/2/2013 closed 11/21/2013 KD Region 1 _Cornwall Consolidated 8/22/2013 45 days 10/1/2013 11/4/2013 closed 11/4/2013 KD Ledyard Public Schools (H.S.) Waterbury Alpha & 9/13/2013 45 days 11/8/2013 KD Omega Christian phone- Academy 9/30/2013 45 days 11/21/2013 NO RESPONSE K991304160‐CT AHERA JFB Notices of Noncompliance Issued by DPH (Aug 2009 through May 2012)

Yeshiva Waterbury - resend to individual Yeshiva schools 9/30/2013 45 days NO RESPONSE

Manchester-Community phone- Child Guidance Clinic, 10/8/2013 45 days 11/28/2013 New AMP submitted Closed

NEW AMP Meriden, Connecticut submitted 3/19 & Christian Academy 10/8/2013 45 days 19-Mar-13 5/12/14 Closed 5/30/2014

phone calls; Earl Windsor-Madina Clark to develop Academy 10/8/2013 45 days plan NO RESPONSE

The Lighthouse, Groton 10/22/2013 45 days Closed

The Village for Families and Children 11/8/2013 45 days 11/20/2013 1/14/2014 Closed 1/14/2014 KD

Yeshiva K'Tana K-8 School, Waterbury 12/3/2013 NO RESPONSE

Yeshiva Waterbury Gedolah H.S. 12/3/2013 45 days NO RESPONSE

Watkinson School, 1/23-start; Hartford 12/6/2013 12/11/2013 45 days 1/15/2014 7/18/2014 Closed 7/21/2014 KD

Bridgeport Fairchild Wheeler Interdistrict 12/16/2013 45 days 12/27/2013 AMP approved Closed 2/14/14 LG

Litchfield Center and Intermediate 12/27/2013 1/6/2014 45 days initial-1/28/2014

initial 2/28; 3/3/14 DPH response, Berlin- Moreland 2/4/2014 2/7/2014 45 days initial 2/28/14 4/22; Closed 1/26/2015 KD

Trumbull-Middlebrook 2/6/2014 2/10/2014 45 days 3/21/2014 3/31/14 KD Closed 3/31/2014 KD

Kensington, St.Paul 3/21/2014 3/25/2014 60 days 5/6/2014 8-Jan-15 Closed 1/8/2015 KD K991304160‐CT AHERA JFB Notices of Noncompliance Issued by DPH (Aug 2009 through May 2012)

Manchester, East July 7, 2014 & Catholic 3/28/2014 3/31/2014 60 days 6/27/2014 October 31, 2014 Closed KD 10/31/2014 Plainville, Wheeler Clinic 3/28/2014 3/31/2014 60 days 4/21/2014 4/21/2014 Closed 4/21/14 KD Wethersfield-Emerson- Williams 4/16/2014 4/21/2014 45 days 5/30/2014 6/23/2014 Closed KD 6/23/2014 Hartford Public Schools Breakthrough II 7/8/2014 7/10/2014 45 days no response Hartford Public Schools Achievement First 7/8/2014 7/10/2014 45 days no response

Greenwich, Eagle Hill School 8/21/2014 8/25/2014 60 days 9/22/2014 under review/ more info requested

West Hartford, mulitple Kingswood Oxford 9/5/2014 9/10/2014 60 days responses 1/23/2015 Closed KD 1/26/2015

Diocese of BPT, St. Jude School, Monroe 10/7/2014 10/9/2014 60 days 1/6, 1/8 1/8/2015 Closed KD 1/8/2015

Milford, The Foundation School 10/7/2014 10/8/2014 45 days 11/5/2014 11/5/2014 Closed LG- 11/5/2014

Natchaug Hosp/Joshua Center, Manfield, Norwich, Old Saybrook, Willimantic 10/7/2014 10/8/2014 45 days 11/17/2014 23-Dec-14 Closed KD 12/23/2014

Montville Public Schools (Palmer) 11/21/2014 11/25/2014 30 days 12/12/2014 1/9/2015 Closed KD 1/9/2015

New London Public 60 days, submitted new Response to NON included 3 new Schools 12/4/2014 12/8/2014 2/6/15 AMPs 8/26/15 9/17/2015 Closed KD 9/17/15 AMPs

New Britain Public Schools 12/23/2014 12/29/2014 60 days 3/26/2015 under review/ more info requested

Norwich Integrated Day Charter 1/7/2015 1/9/2015 60 days 3/9 & 3/19/15 Norwich DIocese_St. Michael, Pawcatuck 1/9/2015 1/15/2015 60 days 3/18/2015 3/18/2015 KD 3/18/2015 K991304160‐CT AHERA JFB Notices of Noncompliance Issued by DPH (Aug 2009 through May 2012)

Milford_Christian Academy (Berean) 1/14/2015 1/20/2015 60 days 1/23/2015 2/23/2015 Closed KD 2/23/15 RSD #1 North Canaan E.S. 1/16/2015 1/22/2015 60 days 3/25/2015 New Canaan (East and Saxe) 1/23/2015 2/3/2015 60 days 3/27/2015

Wolcott Public Schools (High School) 2/25/2015 3/3/2015 60 days Darien Public Schools, Hindley and Middlesex 06252014 3/10/2015 3/16/2015 60 days

Norwich Diocese Sacred Heart 05282014 3/10/2015 3/13/2015 60 days 5/8/2015 completed closed KD 5/26/2015

Advisory Letter Pomfret Community School 6/23/2015 NA NA NA NA closed LG 6/23/15

Manchester Odyssey Charter School 7/22/2015 7/28/2015 60 days OPEN Suffield Public Schools, McAlister Intermediate and A Ward Spaulding School 7/22/2015 7/24/2015 60 days Advisory Letter- Bridgeport Public Schools- Harding H.S. 7/27/2015 NA NA NA NA closed LG 7/27/2015

Manchester Public Sh (Keeney, Washington, Begin Review Board) 7/28/2015 7/30/2015 60 days 9/21/2015 9/25/15 closed KD 9/28/15 CD ROM begin West Haven Public with 3 yr reins Schools, Carrigan and 09/18/2014 & Washington 7/28/2015 7/30/2015 60 days 9/23/15

CantonWaterbury Public Public Schools 9/1/2015 9/4/2015 60 days 1/15/2016 2/2/16 need more Schools (3) Bucks Hill, Northend/Wilby HS, Wallace MS 9/15/2015 9/18/2015 60 days 12/14/2015 12/15/2015 closed KD 12/15/15 K991304160‐CT AHERA JFB Notices of Noncompliance Issued by DPH (Aug 2009 through May 2012)

Middletown Public Schools, Macdononough School 9/28/2015 10/2/2015 60 days 10/29/2015 completed closed KD 10/29/15

The Woodhall School 10/20/2015 10/27/2015 45 days 11/25/2015 Church of Fairfield, Great Beginnings Montessori 10/22/2015 10/29/2015 30/60 days

Cheshire Academy 10/27/2015 10/29/2015 60 days

Suffield Academy 11/18/2015 11/27/2015 60 days 1/15/2016 Under review/ new AMP submitted letter sent 2/2/16 Pomfret Rectory School 110614 3/17/15 3/20/2015 60 days 5/5/2015 10/30/2015 closed KD 12/21/2015 Advisory Letter Bridgeport- Bridge Academy 7/28/2015 NA NA NA NA closed LG 7/27/2015