Reporting Template and Compliance Statement – Ministry of Education

Reimbursement of Costs related to the

Provision of Alternative Drinking Water Supply and/or Water Filters

To Address Exceedances in Lead in Drinking Water


DUE: FEBRUARY 13, 2009

As part of their agreement with the Ministry of Educationto receive fundingfor the provision of alternative water supply and/or water filters in schools with exceedances in lead in drinking water, every board is required to provide a report and compliance statement,no later thanFebruary 13, 2009,forcosts incurred up to and including January 31, 2009.This template is for this purpose. Costs incurred afterJanuary31, 2009 will be reported in a similar manner at a later date.

Please submit this report and compliance statement (boards that have not incurred costs are requested to file a NIL report), signed by the Director of Education or other board authorized signing officertoyour Regional Manager, Ministry of Education.

If you require further information, please contact your Regional Office for assistance.

Part 1:

Name of District School Board or School Authority
Primary Contact Information
Job title:
Name of School / SFIS No. / Items: bottled water, paper cups, water dispensers, rental or purchase of coolers, water filters / Costs
Total Cost

Part II:Summary of Actions taken to date

Provide a brief summary of the provision of alternative water supplyand/orwater filters for your schools:

Part III: Plans for Follow-Up and Additional Support

How will your board continue to provide support to your schools which continue to deal with the presence of lead in drinking water?

Part IV: Compliance Statement

1.Financial Contractual Obligations:

I hereby declare that our board has spent funds to provide alternative water supply and/or filters as per the terms of memorandum 2007:SB26 - Ministry of the Environment Protocol for Ontario Regulation 243/07 Facilities which Exceed the Ontario Drinking Water Quality Standard for Lead, datedSeptember 24, 2007.

2.Financial Spending Obligations:

a) I certify that our board has spent $______under this initiative.

b) The spending records are subject to Ministry audit whenever requested.

Name of Board: ______

Director of Education (or Other Board Authorized Signing Officer):


(signature)(please print name)

Date: ______