Property History Questions for Child Care Center and Group Child Care Home Applicants

Please complete the form on the next page after reading the instructions on this page. This form collects information about how the property and buildings at your child care center or group child care home were used in the past. Some past uses such as agricultural or manufacturing/industrial could have left chemicals behind on the land or in the buildings. The information you provide will help the Department of Public Health identify whether residual chemicals may be present at your child care property and will help the Department ensure that actions are taken (if needed) to make the property safe. Please note that if you are Family Child Care Home applicant and your program will operate in a private residential structure, you do not need to complete this form. Please answer the questions on the next page to the best of your ability and go back in time as far as readily available information allows.

We strongly recommend that you talk with the following people to help you complete this questionnaire.

• Property Owner (if applicable)
• Local health department (LHD). For help finding your LHD: http://www.ct.gov/dph/cwp/view.asp?a=3123&q=397740External
• Town Planner/Town Zoning Office
• Town Engineer/Town Building Department

Other resources that may be helpful to you:

• Town tax assessor
• Town land records
• Local fire marshal
• Local economic development agency

If you have questions about completing this form, please contact Sharee Rusnak of the CT Department of Public Health Environmental and Occupational Health Assessment Program at 860-509-7740 or sharee.rusnak@ct.gov. For answers to questions regarding child care licensing regulations, requirements and applications, call the Office of Early Childhood at 1-800-509-8045.

General Information

Applicant Name__________________________________________________________________________

Name of Child Care Center/Group Child Care Home______________________________________________

Child Care Center/Group Child Care Home Address ______________________________________________

Property History Questions

1. 1. Current owner of Child Care Center/Group Child Care Home property____________________________
   2. Has the Child Care Center/Home ever gone through a SAFER referral before?
      

      o  YES

      o  NO

      o  UNKNOWN

      a. If yes, when and under what name__________________________________________________

   3. Child Care Center/Group Child Care Home building was constructed in what year?__________________
   4. Was the Child Care Center/Home land or buildings ever used in the past for any of the following?

• • • o  Dry Cleaner o  Gas Station o  Auto Repair/Auto Painting Shop o  Retail/Commercial o  Undeveloped o  La Child Care o  Unknown

      o  Metal Plating o  Shooting Range o  Farming/Agriculture o  Landfill/Dump o  Hair Salon/Nail Salon o  Factory/Manufacturing/Industrial o  Funeral Home o  Other ________________________

  5. For any past use boxes you check, provide additional information, to the best of your ability. Attach additional pages if providing information for more than one type of past use.
     a. Name of property owner _________________________________
     b. Owned/operated during what years? _________________________
     c. Company/Business name ___________________________________
     d. If factory/manufacturing past use, describe the type of manufacturing/products manufactured. For any other past uses, provide details about the business, if known: _______________________________________________________________________________________________
     _______________________________________________________________________________________________
  6. Have any of the following documents ever been prepared for the child care property?

• • 1. If yes, are they available?

• 7. Have you seen anything on your day care property that makes you think that hazardous chemicals could have been used there in the past? For example, metal barrels or drums, discarded car parts, construction debris, farm equipment?

• • 1. If Yes, please provide further details ______________________________________________________ _____________________________________________________________________________________________
       _____________________________________________________________________________________________