“Building partnerships, changing lives” /
CAMPUS DIRECTOR
BUILDING & PLAYGROUND MONITORING FORM
CAMPUS: ______MONTH: ______page 1 of 2
Week # 1______
Date: / Week # 2
______
Date: / Week # 3
______
Date: / Week # 4
______
Date: / Week # 5
______
Date: / AREAS MONITORED
(Initialnote the day of week monitoring performed) CAMPUS INTERIOR
Kitchen & other floors/baseboards clean
Kitchen counters clean & all food put away
and properly stored
Menus are posted in their assigned areas
Allergy List Posted in classrooms in assignedareas.
Bathroom/s clean—dust free & in good workingcondition
Adequate supply toilet paper, soap, and hand towels in
bathroom/s
All hazards have been removed i.e.(toxic cleaning
supplies are kept outof children’s reach, including
bathroom areas)
All trash is located in trash receptacles with lids
All Furniture and fixtures free of dust
Tables, glass doors, and mirrors are clean
Glove dispensers are replenished with 1box of
Latex and/or Vinyl gloves when Latex Allergy isknown.
Food handler gloves available for meals
Toothbrush containers cleaned each Friday per protocol
Child/staff ratio is maintained indoors & outdoors
Broken equipment/furniture has beenremoved
or repaired
All floors, doors, ceiling & walls are in good/safe
condition
All electrical outlets are covered
All indoor equipment/furniture is maintained
in good/safe condition for children’s use
All storage rooms are locked
A/C & H control is maintained between 72 and
84 degrees
All doors and pathways remain unblocked
at all times, includes naptime
At least one staff person certified in CPR/1st Aid is in each room during all hours of operation
Maintenance/Custodial duties performed and checklist
completed as required
All Campus Directors (ISD campuses included) must monitor all items listed and document the date monitoring performed
List findings and/or actions taken in comment section. Submit completed forms to Health Specialist by the 5th of each month.
CAMPUS DIRECTOR
BUILDING & PLAYGROUND MONITORING FORM
CAMPUS: ______MONTH: ______page 2 of 2
Week # 1______
Date: / Week # 2
______
Date: / Week # 3
______
Date: / Week # 4
______
Date: / Week # 5
______
Date: / AREAS MONITORED
(Initial & note the day of week monitoring performed) CAMPUS EXTERIOR
All playground equipment is free from rust, cracks, splintered or rotten wood, and peeling paint.
No loose or protruding bolts or screws, nails,
missing or broken parts, sharp points or rough
edges
No trash, debris, sharp limbs, broken glass, tools,
or machinery in play area
Surfacing material is maintained including
appropriate depth of loose fill materials
No tripping hazards, such as large rocks or
roots above ground or cement anchoring
No standing water in objects, such as water drains
from yard
No mold, algae, or fungus noted on or around play area
Grass trimmed, no weeds, branches that present
a hazard when children are climbing, running,
or walking
No berries, flowers, or thorns that present
a choking or poison hazard
Fencing is in good repair at all points, with no gaps or crawl space
No gaps or openings in guardrails, or climbing/play equipment that may cause entrapment or crushing, no objects
protruding that may catch clothing
Maintenance/Custodial duties performed and
checklist completed as required
COMMENTS AND/OR ACTIONS TAKEN: (i.e. Mat Tickets etc.)
All Campus Directors (ISD campuses included) must monitor all items listed and document the date monitoring performed
List findings and/or actions taken in comment section. Submit completed forms to Health Specialist by the 5th of each month.
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Campus Director Signature Date revised 4/2013