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Cover Sheet for Example Documentation Please Complete 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. This document is not intended to be a template, but is a reference as state health agencies develop and select accreditation documentation specific to the health department's activities. Please note that the inclusion of documentation in this library does not indicate official approval or acceptance by PHAB. 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.
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