OCFS-LDSS-7041 (8/2006) Page 1 of 3
NEW YORK STATE
OFFICE OF CHILDREN AND FAMILY SERVICE
DIRECTIONS FOR COMPLETING
THE ENVIRONMENTAL HAZARDS STATEMENT
Complete sections 1 or 2 on the Environmental Hazard Statement after reading the Environmental Hazard Guidance Sheet.
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SECTION 1: NO ENVIRONMENTAL HAZARDS
If you DO NOT find any hazard, check NO. That means, to the best of your knowledge, there are NO potential environmental/ health hazards at or near your child care program site. No additional information is required from you at this point. Do not fill in the Environmental Hazards Information Form, Parts I and II.
If you need technical assistance, please contact an Office of Children and Family Services Representative.
(A site inspection completed by an OCFS representative may result in the need for further documentation or inspection.)
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SECTION 2: YES, ENVIRONMENTAL HAZARDS
If you DO find any hazard, check YES. By checking yes you are claiming that, to the best of your knowledge, there MAY BE potential environmental/ health hazards known at the program site or the surrounding area. If you have checked yes, you must fill out the Environmental Hazard Information Form, Parts I and II.
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OCFS-LDSS-7041 (8/2006) Page 2 of 3
NEW YORK STATE
OFFICE OF CHILDREN AND FAMILY SERVICES
Environmental Hazards Statement
All applicants must complete this form.
Applicants must read all attached guidelines before completing this form.
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Applicant Name: |
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Site Address |
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Facility/Program Name: |
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Facility # (on application or renewal booklet) |
♦♦♦Please complete Section 1 OR Section 2 below♦♦♦
SECTION 1: NO ENVIRONMENTAL HAZARDS
To the best of my knowledge, NO potential environmental health hazard(s) exist either on the day care site and/or surrounding areas. NO (check here)
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OCFS-LDSS-7041 (8/2006) Page 3 of 3
SECTION 2: YES, ENVIRONMENTAL HAZARD(S)
To the best of my knowledge, a potential environmental hazard(s) exists either on the day care site or the surrounding area. YES (check here)
You are required to provide supporting information on the Environmental Hazard Information Form, Parts I and II. You must submit all relevant information with your application. An OCFS representative will review the information and determine whether more information or additional evaluation is necessary.
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Tags: ocfsldss7041, state, (82006)