Parent and School Self - Assessment Tool

Environment Mitigation and Adaptation Evaluation for Schools

_________________________________________________________

Print School Name and Address

Risk Exposure to Environmental Toxins

Click or Copy the Web links ( below ) into the address bar on the INTERNET and follow directions to FIND WHAT? toxins are in the area of your school to complete this self-assessment tool.

SECTION I

Exposure to Greenhouse Gas ( Ozone)
Circle? Yes or No

WEB LINK: http://lungaction.org/reports/sota07_msg_no_monitor.html?msg=0

Exposure to Particular Matter
Circle? Yes or No

WEB LINK: http://lungaction.org/reports/sota07_msg_no_monitor.html?msg=0

Exposure to Industrial Chemicals
Circle? Yes or No

WEB LINK: http://content.usatoday.com/news/nation/environment/smokestack/index

LIST CHEMICALS BELOW

1)

2)

3)

4)

5)

6)

7)

Exposure to Ionizing Radiation ( RADON)
Circle? Yes or No

WEB LINK: http://www.epa.gov/radon/zonemap.html

WHICH ZONE LEVEL IS YOUR SCHOOL IN?

Check one.

ZONE 1 __
ZONE 2 __
ZONE 3 __

SECTION II

Exposure to Non-Ionizing Radiation of EMF ( Electromagnetic Fields)
Circle? Yes or No

WEB LINK: http://www.city-data.com/

Answer the questions below.

1) Do you have cell phone mast or antennas in the area of your school?
Circle? Yes or No

2) Are they within 2 miles of the school?
Circle? Yes or No

1.a) How many cell phone masts?

1.b) How many cell phone antennas?

3) Do you have any power transformers near your school?
Circle? Yes or No

4) Do you have any power lines ( above the ground) near your school?
Circle? Yes or No

5) Do you have wireless connectivity in your school?
Circle? Yes or No

5.a) How many wireless sources are also accessible in your school from businesses Or residences near the school?

6) Do you have UV lighting or Mercy Light Bulbs in your school?
Circle? Yes or No

7) Do you have computers in your schools?
Circle? Yes or No

7.a) For surveillance or an alarm system ?
Circle? Yes or No

7.b) For data / word processing?
Circle? Yes or No

7.c) For telephone (landline) use?
Circle? Yes or No

7.d) For telephone ( cordless) use?
Circle? Yes or No

7.e) For telephone ( mobile) use?
Circle? Yes or No

7.f) For intercom use?
Circle? Yes or No

7.g) For RADIO Station use?
Circle? Yes or No

7.h) For SHORT WAVE RADIO use?

Circle? Yes or No

7.i) OTHER

7.j) OTHER

7.k) OTHER

7.l) OTHER

Write Yes __or__ No to the questions below.

8) Does your staff students work within 3 ft of computers?

9) Does your staff students work within 3 ft of a copier?

10) Does your staff students work within 3 ft of a wall with an electrical current?

11) Does your staff students work within 3 ft of a wireless router?

12) Does your staff work with computers more than one hour per day?

13) Does your students work with computers more than one hour per day?

SECTION III

Environmental Mitigation and AdaptationTechnologies

Do you have indoor mitigation venting fans that exhaust:

1) Industrial Chemicals Circle? Yes or No

2) Greenhouse Gases Circle? Yes or No

3) Particular Matter Circle? Yes or No

4) Ionizing Radiation ( RADON) Circle? Yes or No

Do you have mitigation technologies that block, reduce or harmonize Electromagnetic Field radiation or EMF in:

1) Wireless Technologies Circle? Yes or No

2) Computers Circle? Yes or No

3) Copy Machines Circle? Yes or No

4) Telephones ( including cell phones) Circle? Yes or No

5) Wall Currents ( 60Hz) Circle? Yes or No

6) Fuse Boxes Circle? Yes or No

7) Lighting Circle? Yes or No

Does your school provide Protective Equipment for staff and students working with energized machinery, including Bio-Shields for personal protection? Circle? Yes or No

What kind of equipment?

1)

2)

3)

Has your school installed mitigation devices in school buses or maintenance vehicles?

Circle? Yes or No

What kind of equipment?

1)

2)

3)

Self-Assessment Completed By:

Name_________________________________________________

eMail_________________________________________________

Phone_____________________Mobile______________________

School Name __________________________________________

School Address_________________________________________

School Phone __________________________________________

COMMENTS: Please FAX to 866 279 9181 to Request a Consultation for Environmental Mitigation and Adaptation of your school. http://www.safegreenschools.com/


SAFE GREEN SCHOOLS SERVICE EVALUATION AND FOLLOW-UP: