Form Ehs 1163 - Inspection Of School - N.c. Department Of Health And Human Services

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N.C. Department of Health and Human Services
Score: _____________________
________________________________
Division of Public Health
Health Department
Environmental Health Section
Date of Insp/Chg ____________
Current Facility ID
Inspection of School
Status Code:________________
Old Facility ID
Water Supply:
Community
Non-Transient Non-Community
Water sample taken today?
Yes
No
Transient Non-Community
Non-Public Water Supply
Inspection
Name Change
Re-Inspection
Verification of Closure
Wastewater System:
Community
On-Site System
Visit
Status Change
Name of School: _________________________________________________________________________________________________________________
Location Address: ____________________________________________________________ Mailing Addr. _____________________________________
___________________________________________________________________________
__________________________________________________
City: ______________________________
State: NC
Zip: ________________
City: _____________________________
State: _____ Zip: _________
Score
Comments
1. WATER SUPPLY: Approved water supply properly located,
___________________________________
constructed, and operated, adequate for all requirements 130*; well
house clean, no storage 15*; no cross connections 30* (.2405) ...........
175 ________ ___________________________________
2. SANITARY SEWAGE DISPOSAL: Sewage collected, treated, and
___________________________________
disposed of by an approved method 150*; system properly operated
and maintained 55* (.2407) ....................................................................
205 ________ ___________________________________
3. DRINKING FOUNTAINS: Clean and in good repair 40#; adequate
___________________________________
pressure, properly regulated 40# (.2406) ...............................................
80 ________
___________________________________
4. TOILET FACILITIES: Walls and ceilings clean, nonabsorbent,
washable, and in good repair 30#; fixtures clean and in good repair
___________________________________
40#; floors impervious, kept clean 30# (.2408) ......................................
100 ________
___________________________________
5. LAVATORY FACILITIES: Fixtures clean and in good repair 30#; soap
and individual towels or approved hand-drying devices provided 40#
___________________________________
(.2409) .....................................................................................................
70 ________
___________________________________
6. FLOORS: WALLS: AND CEILINGS: Floors, walls, and ceilings clean
and in good repair 30# (.2410) ...............................................................
30 ________ ___________________________________
7. STORAGE SPACES: Clean 20#; storage off floor 20# (.2411) ...............
40 ________ ___________________________________
8. LIGHTING AND VENTILATION: Fixtures, grills, vents, blinds, drapes,
___________________________________
etc., clean and in good repair 40# (.2412) ..............................................
40 ________
___________________________________
9. DRESSING ROOMS AND SHOWERS: Floors, walls, and ceilings
clean, in good repair, washable, non-absorbent 30#; fixtures clean, in
___________________________________
good repair 40#; facilities for storage of clothes provided, kept clean
20#; soap and towel 10* (.2413) ............................................................
100 ________ ___________________________________
10. SOLID WASTE DISPOSAL: Impervious, cleanable containers with
___________________________________
lids, approved type 20*; clean and in good repair 20#; empties as
needed, properly disposed of 40# (.2414) .............................................
80 ________ ___________________________________
11. PREMISES: MISCELLANEOUS: Premises neat, clean 30#; no vector
___________________________________
breeding or harborage 20#; pesticides and other toxic materials
properly handled and stored 30* (.2415) ...............................................
80 ________ ___________________________________
Additional Comment Sheet Attached
TOTAL
1000________
Yes
No
Inspection by: _______________________________________________________ EHS I.D.# __________________
INSTRUCTIONS Purpose: General Statute 130A-236 requires the Commission for Health Services to adopt rules governing the sanitation of public, private, and religious schools. This
form has been developed to record the results of such inspections. Preparation: Local environmental health specialists shall complete the form every time they conduct an inspection.
Prepare an original and two copies for: 1. Original to be left with principal. 2. Copy for the local health department. 3. Copy for the Environmental Health Section.
Disposition: Please refer to Records Retention and Disposition Schedule 8.B.6., Inspection Records for County/District Health Departments which is published by the North Carolina
Division of Archives & History. Additional forms may be ordered from: Environmental Health Section, 1632 Mail Service Center, Raleigh, NC 27699-1632, (Courier 52-01-00)
EHS 1163 (Revised 7/12)
Environmental Health Section

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