New Jersey Department of Health

Consumer, Environmental and Occupational Health Service

Environmental and Occupational Health Assessment Program

PO Box 369, Trenton, NJ 08625-0369

Child Care Center - Indoor Environmental Health Assessment

Form C: descriptions and conditions of Building components

Facility Name

Street Address

City

County

Directions: Check the component to be evaluated and then provide an evaluation of what was checked.

I. Interior Components (Describe the Condition of Each)
Walls

Floors

Ceilings

Windows

Doors

Stairs

Other, Specify:

II. Exterior Components (Check all that apply and describe condition)
Siding Type (check all that apply and include any siding underneath visible siding):

Wood Clapboard	Brick	Asbestos Shingle

Wood Shingles	Stone	Other Shingles

Aluminum/Vinyl Covered	Masonry	Other, Specify: _________________________
Describe condition of siding materials indicated above:

III. Additional Building Components
Indicate any additional building components (inside or outside) which might be of concern:

Child Care Center - Indoor Environmental Health Assessment

Form C: descriptions and conditions of Building components

(Continued)

CEHS-3

AUG 12	Page 2 of 2 Pages.

AUG 12	Page 1 of 2 Pages.

CEHS-3, Form C: Description and Conditions of Building Components

CEHS-3, form c, description and condition, building components, child care center, indoor environmental health assessment

ewhite

2012-03-19

NJDOH