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INDIANA 5-STAR ENVIRONMENTAL RECOGNITION PROGRAM FOR CHILD CARE FACILITIES APPLICATION
State Form Number 49200 (R4 / 8-07) Indiana Department of Environmental Management

Office of Pollution Prevention and Technical Assistance 100 North Senate Avenue, MC 64-00 Indianapolis, IN 46204-2251 Internet: www.in.gov/IDEM/childcare

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INSTRUCTIONS: The Indiana Department of Environmental Management awards stars for the Indiana 5-Star Environmental Recognition Program for Child Care Facilities on a triannual basis. The application submittal due dates are April 1, August 1 and December 1. Eligible facilities must: · Be licensed or registered (operate more than four hours a day, 10 consecutive work days and care for more than five children); · Be in compliance with all applicable state rules and regulations (Head Start facilities must be in compliance with applicable federal regulations); · Meet all criteria for the star category in which they apply; and · Submit a complete and accurate application. TO APPLY: 1. 2. 3. 4. 5. 6. SECTION 1 Facility Name: License or Registration Number: Mailing Address: City: Facility Address: City: County: Type of Application: Contact Person: Phone: ( ) New Renewal Number of stars for which you are applying: Title: E-mail: 1 Star 3 Stars 5 Stars ZIP Code: ZIP Code: Year Building was Constructed: Number of Students:

Read through the criteria on pages two through four. Refer to the Application Guidelines available at www.in.gov/idem/childcare for assistance with application requirements. Determine the star category in which you will apply. Completely and accurately fill in the information requested below for the category in which you are applying. Gather the requested documentation. Mail the completed application and documentation to the address above. APPLICANT INFORMATION

I certify the information in this application is accurate to the best of my knowledge: Official Signatory for Applicant:: MEASUREMENT DATA ­ SUCCESS STORIES Number of Children with Asthma: Number of Asthma Related Absences: Number of Children tested for Lead: Number of Asthmatic Children with Documented Asthma Action Plans: Have you noticed a reduction in these absences since you implemented the 5-star criteria? If so, how much? Amount reduction of pesticide used at the facility: Title:

Please share how your facility has changed since you implemented the criteria of the 5-star program. What changes did you make? What benefits have you received or expect to see occur? The continued funding of this program relies on the information you provide about how this program has made a difference. Please attach additional sheets if necessary.

FOR OFFICE USE ONLY Date Site Visit Conducted: Number of Stars Awarded: Date Lead Risk Assessment Conducted and Number: Date Awarded:

Page 1 of 4 State Form 49200 (R4 / 8-07)

1-STAR CRITERIA

Child care facilities applying for one star must meet the criteria in all categories below. GENERAL Is in full compliance with applicable state and federal rules and regulations. Performs the IDEM environmental self assessment. Call IDEM at (800) 988-7901 or visit www.in.gov/idem/childcare. Identifies staff member as Facility Environmental Health Designee. CLEANING AND MAINTENANCE Cleans facility diligently and thoroughly at least once daily. Performs maintenance and cleaning when children are not present. Disposes of fats, oils, and greases properly ­ never down the drain. Reduces clutter and unnecessary items throughout the facility. Stores toxic substances (i.e. cleaning materials, detergents, etc.) in original containers and out of reach of children. Uses these substances as recommended by the manufacturer. TRAINING Facility Environmental Health Designee reads environmental health literature and attends workshops and seminars (when available) to ensure understanding and practice of environmental, health, and safety requirements. Trains staff to address environmental commitments made at each star level. Provides annual universal precautions training for employees and maintains a copy of the Bloodborne Exposure Plan on site. Provides annual hazard communication training for employees and maintains the following on site: · A list of chemicals/cleaning materials used and kept at your facility. · Materials Safety Data Sheets for the materials at your facility. Provides annual emergency and fire safety training. LEAD Flushes cold-water pipes and water fountains 30 seconds before cooking or drinking. Uses cold water for cooking. If facility built prior to 1978, uses lead safe cleaning practices to reduce lead dust. Assumes soil outside facility or with neighboring facility is contaminated with lead. Keeps children away from bare soil or potentially contaminated areas. Uses entrance mats and cleans them regularly. Purchases lead-free toys and disposes of recalled toys containing lead as directed by recall notices. Distributes lead poisoning prevention information to parents. ENERGY EFFICIENCY Investigates opportunities to reduce energy use at the facility, such as energy efficient heating and cooling equipment and lights. Seeks products that carry the EnergyStarTM label. RECYCLING Uses two sides of paper when possible. Reuses the blank sides of rejected copies for scrap. Contacts local solid waste management district (in Marion County, contact Keep Indianapolis Beautiful) to investigate recycling options for glass, cardboard, aluminum, plastic and paper, as applicable. PEST CONTROL Diligently cleans rooms where food is eaten or stored. Records types, amounts and locations of pesticides used. Notifies parents and staff before using pesticides. Ensures pesticide contractor uses the least toxic pesticide and that it is never applied when children are present. Uses pesticides and fertilizers according to manufacturer's directions including ensuring minimum re-entry times are adhered to. INDOOR AIR QUALITY Prevents carbon monoxide poisoning by not operating gaspowered machinery indoors. Implements a no smoking policy on facility property. Installs a carbon monoxide detector if gas powered equipment (i.e. floor polishers) or appliances are used in the facility. Distributes information on respiratory illnesses to parents. EDUCATION Distributes environmental, health and safety literature to parents. MERCURY Recycles thermometers containing mercury and replaces them with digital or other non-mercury alternative thermometers. IDLING Reduces vehicle idling at the facility by implementing the following idling limits for vehicles owned by the child care facility: · At 32 degrees or above, vehicles will be allowed to idle for up to 5 minutes; · From 20 degrees to 32 degrees, vehicles will be allowed to idle for up to 15 minutes · From 20 degrees and below, vehicles will be allowed to idle for up to 30 minutes or until front windows are defrosted and all safety equipment is operable.

Page 2 of 4 State Form 49200 (R4 / 8-07)

3-STARS CRITERIA

Child care facilities applying for three stars must meet the one-star criteria in all categories on page two and the criteria in all categories on this page. TRAINING Allows and encourages other internal staff members, including maintenance and housekeeping staff, to attend environmental health training opportunities when available. LEAD If facility built prior to 1978, contacts IDEM or the local health department and requests a lead risk assessment or employs a licensed contractor to conduct a lead risk assessment. Please include a copy of the report with this application. (Not necessary if IDEM performs the assessment.) Encourages parents to take children for blood lead test, as appropriate. ENERGY EFFICIENCY Trains staff to turn off lights when rooms are not in use or when lights are not needed. RECYCLING Takes recyclables to drop-off facility or arranges for other services (e.g. partnering with neighboring business or contracting with a private hauler for pick up). PEST CONTROL Implements basic integrated pest management (IPM) strategies (e.g., monitoring for type and location of pests, caulking, proper food storage, targeted baiting, screens for windows). If facility has pests, licensed contractor uses effective integrated pest management strategies, such as using targeted baits for persistent pests rather than spraying. If you use a contractor, please include a copy of your contract with this application. Contract must state IPM as the preferred management strategy. INDOOR AIR QUALITY Performs annual preventive maintenance on heating ventilation and air conditioning system. Takes actions to reduce mold, fungi and allergens, including repairing leaks immediately, replacing damaged ceiling tile and removing carpet when possible. Avoids fumes, odors, and strong scents (e.g. perfumes, hair spray, deodorizer, cleaning products, etc.). Notifies parents if pets with fur or feathers are present. Removes pets with fur/feathers from rooms where children with respiratory illness or allergies are present. Encourages parents of children with respiratory illnesses to work with healthcare providers to develop an individual asthma action plan. EDUCATION Informs parents of environmental health hazards identified and the actions facility is taking to address them. Incorporates environmental awareness into curriculum. MERCURY Identifies all products containing mercury on-site. Keeps mercury spill kit on premises if liquid mercury is present in facility. Recycles thermostats containing mercury and replaces them with digital or mercury-free thermostats, or identifies thermostats containing mercury with stickers as a reminder to recycle them and to purchase a non-mercury replacement at the end of their useful life. Call IDEM to obtain these stickers. Investigates options for recycling fluorescent bulbs. IDLING Informs parents on the dangers of idling exhaust. Discourages idling near entrances/exits of facility. OUTDOOR AIR QUALITY Signs up to receive local air quality action day warnings at www.in.gov/apps/idem/smog/. Avoids cutting grass or blowing leaves when children are present. ASBESTOS Does not make new purchases of asbestos containing materials (ACM). During maintenance and repair, verifies that friable ACM will not be disturbed. If disturbance of friable ACM will occur, ensures repairs/removal are performed by a licensed asbestos contractor and parents are notified. RADON Performs short-term radon test per instructions. No action needed if results are less than 4 pCi/L. Please include a copy of the test result with this application. If above 4 pCi/L, performs follow-up test. If above 4 pCi/L after follow-up test, contracts with statecertified radon inspector to perform professional testing and develops radon action plan. POLYCHLORINATED BIPHENYLS (PCBs) If PCB-containing electrical transformers are present near facility, requests that utility company replace transformers with ones that do not contain PCBs. (Call utility company to determine whether a nearby transformer contains PCBs.)

Page 3 of 4 State Form 49200 (R4 / 8-07)

5-STARS CRITERIA

Child care facilities applying for five stars must meet the one-star criteria in all categories on page two, the three-star criteria in all categories on page three and the criteria in all categories on this page. LEAD If lead hazards exist at the facility, develops and implements plan to eliminate lead hazards. Requests documentation that blood lead testing occurred prior to enrollment or invites a local health agency to perform a lead screening for students. ENERGY EFFICIENCY Selects at least two of the following: · Uses energy efficient lighting, such as compact fluorescent bulbs where possible. · Insulates hot water heater and pipes. · Resets temperature of building when building is unoccupied. · Using air-locks, double sets of exterior doors, to reduce heating and cooling fluctuations. · Installing weather stripping. · Documents other energy efficient activity implemented. RECYCLING Replaces single-use dishware (bowls, plates, utensils, etc.) with approved reusable dishware as health department regulations allow. Investigates the uses of alternative playground mulch made from recycled material. Purchases recycled content paper when possible. Selects products made from recycled materials when possible. PEST CONTROL Attends integrated pest management training when offered. INDOOR AIR QUALITY Establishes a "no fur, no feathers" policy such that the facility does not allow such animals on site. When replacing vacuum cleaners, purchases and uses a HEPA vacuum if carpet is present. EDUCATION Conducts educational programs for parents on environmental issues and their proper management (e.g. open house, newsletter articles). MERCURY Recycles used fluorescent bulbs. (Contact your local solid waste management district. In Marion County, contact Keep Indianapolis Beautiful.) IDLING Displays no-idling zone signs in areas at the facility where parents are likely to idle their vehicles. OUTDOOR AIR QUALITY Prohibits outdoor activities on days when the air quality is poor. Keeps windows closed and uses air conditioning on days when air quality is poor. ASBESTOS If constructed prior to 1985 and planning to renovate, hires a licensed asbestos inspector to perform an asbestos inspection. Hires a licensed asbestos inspector if recommended by IDEM.

Page 4 of 4 State Form 49200 (R4 / 8-07)