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.

1. An “Environmental Health Management” policy statement has been adopted, posted and circulated and program participation has been communicated to our entire staff, students, and parents. Date Adopted
2. A non-toxic/least toxic purchasing policy statement has been adopted, posted and circulated, and program participation has been communicated to our entire staff, students, and parents in our efforts to reduce unnecessary exposures to toxic chemicals. Date Policy Adopted
3. An “integrated pest management” and control program that include written procedures has been adopted and communicated to our entire staff, students, and parents. Date Policy Adopted
4. We have participated in at least one environmental health workshop that was approved or sponsored by the Vermont Department of Health. Please list the title(s) of the workshop(s). 5. A team/committee that represents a cross-section of the school community worked on the school’s “Environmental Health Management” plan for our school property and grounds. Their names and telephone numbers are listed below. Please list the coordinator first. 6. The school’s environmental health management plan includes actions to:

a) reduce hazardous chemical exposures and fix indoor air problems
b) communicate the school environmental health status to students, parents, and staff
c) implement integrated pest management and control program to reduce pesticide exposure
d) physically isolate toxic materials that cannot be eliminated e) integrate policies for emergency response
f) create tools to evaluate the plan.

7. HVAC (heating ventilation and air conditioning) maintenance schedule has been implemented within the last six (6) months, or is scheduled within the next twelve (12) months.

Date Performed (or scheduled date)

Performed by

8. School’s communication efforts – Mark all that apply to notify students, teachers, parents, and the community at large about the environmental health status at the school.

School or local newspaper article
Letter to parents
Indoor air quality suggestion box
Environmental health exhibit at school open house
Public access television
School board meeting update
Press release
Discussion at staff meetings
Parent organization meeting
Memos to staff
Classroom discussions
Student council discussions
Individual telephone calls to parents
Special information meeting to community
Other (briefly describe)

Environmental Health Areas / Section 2 1. As a result of the purchasing policy, a number of products were replaced with least toxic or non-toxic products. Provide examples in the space provided and if necessary attach additional examples on a separate sheet.

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
a)	a)
b)	b)
c)	c)
d)	d)
e)	e)
f)	f)
g)	g)

As a result of this purchasing policy, the school has reduced its use of toxic materials and replaced with safer alternatives by: percent (%). (i.e. replace 2 of 10 commonly used products, or 20%)
2. As a result of the integrated pest management program examples of actions we have used to control pests populations in place of applying pesticides include:

Integrated Pest Management actions	Pesticides replaced by these actions
Example: Dedicating uncarpeted dining areas for students+staff	Example: Spraying for ants
a)	a)
b)	b)
c)	c)
d)	d)
e)	e)
f)	f)
g)	g)

As a result of our integrated pest management (IPM) and control program and procedures, we reduced our use of pesticides and replaced with safer alternatives by: percent (%). (i.e. replace 1 of 3 pesticides with IPM, or 33%)

When pesticides are used – mark all that apply:

The school uses a licensed company employing applicators certified by the VT Agency of Agriculture.
The school staff that apply pesticides are certified as required by the Vermont Agency of Agriculture
Parents are notified in advance of pesticide applications.
Integrated pest management steps are used to control and prevent pest problems in place of routine pesticide applications.

3. Our school identified hazardous materials in the school. Environmental health management practices were used to address those materials (mark all that apply):

Reduce volatile organic compounds or “off gassing” materials Install adequate ventilation above office photocopiers and computer stations
Reduce diesel emissions with parent “pick-up and idling” policy Reduce diesel emissions with bus/delivery truck “idling” policy Test for lead in drinking fountains and take action if level is 15 parts per billion (.015 milligrams per liter) or above
Maintain relative humidity levels below 50% to reduce mold growth
Use materials free of formaldehyde and asbestos for new construction
Eliminate mercury in the school
Other (please describe)

How did you measure success with these environmental health management practices? (please describe below)

4. Our school reduced exposures to environmental triggers to decrease the severity of asthma and allergic reactions reported by students and staff. The measures used to evaluate the impact include the following (check all that apply): (indicate percent # in column if marked)

Decrease in student complaints of headaches and sinus infections by percent
Decrease in staff complaints of headaches and sinus infections by percent
Decrease in visits to nurses office for asthma and asthma treatments by percent
Decrease in bronchitis cases by percent
Increase in reports of student and staff comfort by percent
Other (describe)

5. Our school has implemented healthy cleaning and groundskeeping measures. Examples of actions include (check all that apply):

Replace old carpets with smooth and cleanable material
Seal CCA (chromated copper arsenate) pressure treated playground equipment
Install walk-off mats and floor grates at school entrances to reduce dirt and dust from entering the school
Other (describe)

6. We have tested the school for radon. Mark all that apply. Action level for radon is 4 pci/L of air (picoCuries per liter).

All rooms tested at acceptable levels
One room tested at the action level for radon
More than one room tested at the action level
Other measurements are needed to confirm level
Radon remediation was performed
Other (describe)

7. Our students are involved with “Environmental Health Management” plan efforts. Please mark all that apply indicating students activities:

Youth Environmental Coalition-Association of Vermont Recyclers
The Green Flag Program (www.greenflagschools.org)
Open Airways-American Lung Association of Vermont
Classroom activities
Other (please describe)

8. Our school and staff worked with other schools in our district so that they may learn from our experience and efforts to improve environmental health in our school. List contacts and results below.

Name of school (1) that we assisted:
When did this contact occur?
What was the result? Name of school (2) that we assisted:
When did this contact occur?
What was the result?

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

Attended all meetings/events on indoor air
Acted as spokesperson for school
Recruited individuals to assist with assessment, problem solving, and preventing problems
Acted as indoor air quality educator or trainer
Other (please describe)

9. In the space below please describe briefly what other school environmental health priorities were achieved at your school to improve the air quality, reduce exposures to environmental toxins, and how you measured success.

Contact Information School Name:

Mailing Address: Program Contact and Phone #:
Nominee(s) for outstanding efforts by Student/Teacher/Staff or Parent¹ Optional: Please provide in this space a testimonial to your school’s progress. This can be a statement made by a student, teacher, parent, or staff.

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

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Certificate of Achievement Form

Environmental Health Management Plan and Policy

When pesticides are used – mark all that apply:

Envision program