Your name (optional)

Are you a Student _____ Teacher _____ Parent _____ Other School Employee_____

What is the name or number of your school?

What is the street address/ borough of your school?

Do you consider your school to be a safe space or building [fire, plumbing, air]? Yes__ No__

If No, please explain:

(Please check all that apply)

Blocked fire exits

Broken steps

Inadequate Lighting

Crumbling walls/ceiling

Other (please explain):

What is the most obvious safety violation (if any) that you can think of at your school?

Does your school have a gym? Yes ___ No ___

Does your school have a playground? Yes ___ No ___

Does your school have an auditorium? Yes ___ No ___

2. Personal Health:

Do you have any medical conditions (allergies, asthma, disability, etc.)? Yes ___ No ___

If yes, what are they?

Is your medical condition made worse by the air quality or cleanliness of the school?

Yes ___ No ____

If yes, how (check all that apply):

Indoor Air Quality _____

Pesticide Use _____

Cleaning Fluids _____

Dirt/Garbage _____

Other (please explain)

Do you have any sensitivities to the air or particular fumes in the school building?

Yes ___ No ____

If yes, what about the air or fumes in particular bothers you? Please Explain:

Do you have more frequent or serious asthma or allergy attacks during the school days?

Yes ___ No ____

If yes, what causes your attacks? Please Explain

3. Walls and Ceilings:

Have you noticed any cracks or holes in the walls and ceilings of hallway, gym, or classrooms in your school building? Yes ___ No ___

If yes, where? in Classrooms ____ Hallways____ Auditorium ____ Bathrooms ____ Gym ___

Is the paint peeling anywhere in your school? Yes ___ No ___

If yes, where? in Classrooms ____ Hallways____ Auditorium ____ Bathrooms ____ Gym ___

Is there any exposed wiring? Yes ___ No ____

If yes, where? in Classrooms ____ Hallways____ Auditorium ____ Bathrooms ____ Gym ___

Are there cracks in the ceiling? Yes ___ No ____

If yes, where? in Classrooms ____ Hallways____ Auditorium ____ Bathrooms ____ Gym ___

Does the ceiling leak? Yes ___ No ____

If yes, where? in Classrooms ____ Hallways____ Auditorium ____ Bathrooms ____ Gym ___

4. Windows:

Are any windows painted or nailed shut? Yes ___ No ___

Approximately how many?_____

Where? in Classrooms ____ Hallways____ Auditorium ____ Bathrooms ____ Gym ___

Are any windows broken? Yes ___ No ___

Approximately how many? ______

Where? in Classrooms ____ Hallways____ Auditorium ____ Bathrooms ____ Gym ___

5. Air Quality:

Is the ventilation/air circulation in your school poor? Yes ___ No ___

Do the windows Open? Yes ___ No ___

Does your school have air conditioning? Yes ___ No ___

Does the air conditioning work in your school? Yes ___ No ___

If yes, is it adequate? Yes ___ No ___

Does the heat work in your school? Yes ___ No ___

If yes, is it adequate? Yes ___ No ___

Is there an offensive or musty odor in the building? Yes ___ No ___

If yes, do you know where it is coming from? Yes ___ No ___

If yes, please explain.

Are there fans or vents? Yes ___ No ____ Do they work? Yes ___ No ____

Do the cleaning fluids used in the school have a really strong (toxic) smell? Yes ___ No ___

If yes, are the fumes from cleaning fluids too strong? Yes ___ No ____

If yes, please explain what they smell like and why they are too strong.

Do the fumes from the cleaning fluids cause any medical problems for you or anyone you know?

Yes ___ No ____

If yes, what?

6. Fire Safety:

Are there easily accessible fire extinguishers and/or fire alarms? Yes ___ No ____

If yes, where? in Classrooms ____ Hallways____ Auditorium ____ Bathrooms ____

How many fire exits are there? ___ Are they easily accessible? Yes ___ No ____

Is there a safety strategy for exiting the building quickly and safely? Yes ___ No ____

Are there illuminated fire exit signs? Yes ___ No ____

Do they work? Yes ___ No ____

7. Classrooms:

Are any of your classrooms overcrowded? Yes ___ No ____

If yes, how many students are in the class? 20___ 30___ 40___

Are classes held in nontraditional spaces? Yes ___ No ___

If yes, where? in Hallways____ Auditorium ____ Bathrooms ____ Other ____

Are there enough desks and chairs? Yes ___ No ____

If no, how many are missing?

Are the desks safe and serviceable? Yes ___ No ____

8. Plumbing:

Are there water fountains in your school? Yes ___ No ____

Do they work? Yes ___ No ____

Do the sinks or toilets function properly? Yes ___ No ____

If they break down, approximately how often?

Once a month ___ Once a week ___ Everyday ___ For how long? One month ___ A week ___ A few days ___ A few hours in a day ___

Is there soap? Yes ___ No ____

Is there toilet paper available? Yes ___ No ____

Is the water coming out of the faucet or water fountain ever brown or discolored?

Yes ___ No ____

Does the water have an offensive odor? Yes ___ No ____

Does the water have a funny taste? Yes ___ No ____

9. Hygiene:

Is the cafeteria clean? Yes ___ No ____

Are the eating utensils [forks and knives] clean? Yes ___ No ____

Is the food fresh? Yes ___ No ____

Are the floors clean? Yes ___ No ____

Are spills or food waste cleaned up adequately? Yes ___ No ____

Is there garbage or discarded waste around your school? Yes ___ No ____

Are the bathrooms clean? Yes ___ No ____

Is there a roach or rodent problem? Yes ___ No ____

If yes, how serious do you think it is? Please explain

Do the staircases in your building have handrails? Yes ___ No ____

Are the staircases safe? [free of garbage, debris, and cracks] Yes ___ No ____

Is there satisfactory lighting? Yes ___ No ____

If no, where is the lighting unsatisfactory?

in Classrooms ____ Hallways____ Auditorium ____ Bathrooms ____

10. Outside of the school building:

Are there school buses which stay parked outside? Yes ___ No ____

If so, are their engines ever on? Yes ___ No ____

If yes, for how often? Once a month ___ Once a week ___ A few days every week ___ Everyday ___ For how long? A few hours each day ___ One hour each day ___ 15-20 minutes each day ___

Are there bus depots nearby your school? Yes ___ No ____

Are there waste transfer stations nearby? Yes ___ No ___

Is there a nearby sewage treatment plant? Yes ___ No ___

Is there any external pollution or object near your school that affects the cleanliness or safety of the school environment? Yes___ No ____

If yes, what?

11. Recreational equipment:

Is there safety equipment (rubber padding, matting, etc.) for use on the playground?

Yes ___ No ____

Are there pieces of glass or other debris on the playground? Yes ___ No ____

Is the gym at your school usable (in decent condition, open for use, etc.)? Yes ___ No ____

Does the gym have adequate safety equipment for athletic activities? Yes ___ No ____

If no, what is lacking?

Is there anything else you want to tell us about your school?