Certificate of Achievement Form

Please answer each question that applies by checking the boxes and entering text when space is provided. After the form is complete, print it out and mail it to:

ENVISION Program, Division of Health Protection
Vermont Department of Health
P.O. Box 70 , 108 Cherry Street
Burlington , VT 05402

Questions? Please call 1-800-439-8550 (Vermont only)

Core Standards / Section 1

Environmental Health Management Plan and Policy

ENVISION partner schools will develop an environmental health management plan and policy. For more information on a model plan and policy refer to the ENVISION binder or contact the Vermont Department of Health at (800) 439-8550.

Check the box for those standards your school has achieved. Describe actions in the space provided.

Environmental Health Areas / Section 2
Least Toxic or non-toxic product(s) The product(s) replaced by these purchases
Example replacement: Vinegar and water window wash Example replaced: Ammonia glass cleaner
Integrated Pest Management actions Pesticides replaced by these actions
Example: Dedicating uncarpeted dining areas for students+staff Example: Spraying for ants

When pesticides are used – mark all that apply:

In your contact information you may nominate a student, teacher, staff, or parent for outstanding efforts – Mark all actions that apply to that nominee.

Contact Information

1 Nominees will be invited to the statehouse and school board meeting ceremony with the school’s principal and superintendent.

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