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Property Questionnaire

Welcome!

The Massachusetts Department of Public Health (DPH) wants to help early care and education programs choose locations safe from environmental hazards.

Please submit this form if you would like DPH to check for possible environmental hazards at your child care program's current location or a new location you may be considering. This free service is available to all early care and education programs, including group and school age programs as well as family child care programs.

Why participate? To keep kids safe and help your business succeed! It's free and only takes a few minutes.

For questions or more information, contact us at choosesafeplaces@mass.gov or 617-624-5757. If you would like to complete a paper copy of the Property Questionnaire, a PDF version is available to download and print.

How can we get in touch with you to share the results?

1a. First Name *must provide value
1b. Last Name *must provide value
1c. Pronouns
1d. Phone Number *must provide value
1e. Email Address *must provide value

Please provide the address and status of your early care and education program.

Enter NA if not applicable.

My early education and care program is:

* must provide value

Licensed/Active. Check here if you have an existing program, the program is moving, or you are opening another location.

Not licensed/New. Check here if your program is not open yet.

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My early education and care program is/will be:

* must provide value

Group and School Age Child Care program (center-based)

Family Child Care program (home-based)

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Name of program

* must provide value

Street Address

* must provide value

City/Town

* must provide value

ZIP Code

Where did you hear about the Choose Safe Places for Early Care and Education program?

EEC Licensor

EEC Potential Provider Meeting

Social Media

Internet Search

Friend or colleague

Other

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8a.

Please explain.

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The next questions ask about the property. It is okay if you don't know the answer.

Lead

Lead-based paint could have been used in buildings built before 1978. Infants, young children, and pregnant people are especially vulnerable to the harmful effects of lead.

Was your building constructed before 1978?

Yes

Don't know

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9a.

Has it been inspected for lead paint?

Yes

Don't know

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9b.

When was it last inspected?

9c.

Do you have a Letter of Compliance from a licensed lead inspector indicating that either no lead hazards were found or that deleading was completed to remove lead hazards?

Deleading is work done to remove or cover lead hazards and may include actions like replacing windows or covering (encapsulating) old paint.

Yes

Don't know

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Radon

Radon is a radioactive gas that comes naturally from soil and rocks. Radon can travel from the ground into a building and can cause lung cancer if you breathe it in over many years.

10.

Has the building ever been tested for radon?

Yes

Don't know

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10a.

Were the results above the EPA Action Guideline of 4 picocuries per liter of air (pCi/L)?

Yes, but a mitigation system has been installed

Yes, but a mitigation system has not been installed yet

Don't know

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Property Use and History

Former uses of the property may have left behind harmful chemicals. It is also possible that nearby activities could pollute the air, contaminate groundwater, or leave chemicals on the ground that can wash onto neighboring properties.

11.

Was the building or property used in the past for any of the following businesses or activities? (Check all that apply)

Auto Repair/Auto Painting Shop

Dry Cleaner

Factory/Manufacturing/Industry

Farming/Agriculture

Fire Station/Firefighter Training

Funeral Home

Gas Station

Landfill/Dump/Junk Yard

Old Mill Building/Mill Complex (i.e., paper, tannery, textile mill)

Shooting Range

21E/Superfund/Brownfields Site

Other businesses that may have used chemicals

Don't know

None

11a.

For any boxes checked above, please provide as much additional information as possible.

What was the name of the business? When did it operate? Who was the property owner? What type of activities occurred at the property? Other information?

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12.

Have you seen any of the following at the property? (Check all that apply)

These items may indicate hazardous chemicals were used in the past.

Appliances

Batteries

Construction debris

Discarded car parts

Farm equipment

Metal barrels or drums

Paint cans

None of the above

Other

Don't know

12a.

Please explain.

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13.

Are any of the following businesses in the same building, strip mall, or within eyesight? (Check all that apply)

Art studio (i.e., pottery studio)

Auto Repair/Auto Painting Shop

Copy/Print Shop/3-D Printer

Dry Cleaner

Factory/Manufacturing/Industry

Funeral Home

Gas Station

Hair Salon/Nail Salon

Other businesses that may use chemicals

Don't know

None

13a.

For any boxes checked above, please provide as much additional information as possible.

What is the name of the business? Who is the property owner? Other information?

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Drinking Water

Clean water is important, especially for infants who drink formula made with tap water.

14.

Where does the drinking water come from?

Public water supplier

Private well

Don't know

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14a.

Has the private well ever been tested?

Yes

Don't know

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14b.

Did any contaminants exceed drinking water standards?

Yes

Don't know

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15.

Has the drinking water been tested for lead?

Yes

Don't know

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15a.

Was lead detected?

Yes

Don't know

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Soil

Soil can contain contaminants such as lead, which can enter a child's body if they touch it or put their hands in their mouths after touching it.

16.

Can children touch or play in soil in your outdoor play space?

For example, areas with bare soil, patchy grass, or where wood chips/mulch has worn away.

Yes

Don't know

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16a.

Please explain.

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17.

Does the program have or plan to have a garden used by children?

Using raised beds with clean, purchased soil is the safest gardening method.

Yes

Don't know

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Environmental Assessments

For example, a Phase I or II Environmental Site Assessment.

18.

Has an Environmental Assessment ever been completed for the property?

Yes

Don't know

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18a.

Do you have a copy of the report?

Yes

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19.

Do you have any other reason to think there may be an environmental hazard at the site or nearby?

Yes

Don't know

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19a.

Please explain.

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Recommendations made pursuant to DPH's Choose Safe Places Program are based on publicly-available data and information at the time of the screen. For this reason, DPH cannot guarantee all possible environmental hazards will be identified. If remediation, follow-up testing, or other work is conducted as a result of DPH recommendations, DPH is not responsible for any costs associated with those activities. Please note that any data submitted by the participant or produced by DPH during the site screening process is considered public and will be shared with any party who requests it.

Thank you for participating in the Choose Safe Places program. We will review your responses and contact you with results within a few business days.

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.