PA HEALTHY & GREEN MINI-GRANT APPLICATION WORKSHEET
SECTION 1: APPLICANT INFORMATION
Amount Requested (up to $5,000):
Average Number of Children Served Daily:
Number of Staff:
Age Range of Children Served in Program:
Annual Operating Budget:
Children cared for in lower-level or basement of facility: yes or no (circle one)
Program Name:
Primary Contact and Title:
Address:
Phone:
Fax:
Website:
Email:
Regulated Child Care Providers only - MPI ID#
All Applicants: Keystone STARS Level
Regional Key
County:
Center or Group Provider
Head Start Provider
Currently NAEYC Accredited:
Facility Ownership:
Family Home Provider
PA PreK Counts Provider
Yes
Yes
No
No
Lease or Rent Facility:
Yes
No
Do you have the authority or have you received permission from a building owner/landlord to implement all items or
services requested in this proposal?
Yes
No
Signature and Title of Authorized Official:
Professional Development: (attach certificates)
Eco-Healthy Childcare:
Date Attended:
Name and Title of person who attended:
Project Learning Tree and/or Growing Up WILD):
Date Attended:
Name and Title of person who attended:
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Our Program plans to become certified by Eco-Healthy Child Care© with this grant:
Yes
No
Name and title of authorized person responsible for this application.
SECTION 2: PROGRAM DESCRIPTION
For Official Use Only: (total should equal 30)
# of Checklist Items Already Completed
# of Items to be Completed with grant funds
#of Checklist Items that will not be Completed
Please describe your program’s commitment to children’s environmental health. (500 words or less)
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SECTION 3: GRANT BUDGET SUMMARY
Eco-Healthy Child Care Requests:
Supplies (list)
Cost:
Equipment (list)
Cost:
Furniture (list)
Cost:
Testing Services (provide copy of invoices)
Cost:
Other Types of Services (please list and provide estimates) Cost:
Other (please list)
Cost:
SubTotal
Environment & Ecology Materials
$$
(total request)
$$
Total Grant Funds Request
$$
** Obtain a minimum of two qualified comparative written price quotes or estimates for any single purchase
or professional service the PROVIDER makes with grant funds with an estimated cost of $3,000
or greater. These price quotes must be maintained as part of the recordkeeping files. In the event
the PROVIDER chooses not to select the lowest price quote, the PROVIDER must create a
written justification and maintain this justification with its records for audit purposes.”
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SECTION 4: PROGRAM STATUS WITH ECO-HEALTHY CHILD CARE CHECKLIST©
This checklist is designed to help decision-making for your funding request. Please review the items within
each topic area to determine if your program has completed, is planning to complete or is unable to complete
each one. Keep your answers brief; bulleted format is preferred.
When you select your focus areas for grant application, please remember that you are required to meet all PA
DPW Child Care Licensing Requirements for each topic area as outlined on the PA Reference Pages for EcoHealthy Child Care and DPW Child Care Regulations. Programs are also strongly encouraged to implement
the recommendations of Eco-Healthy Child Care© and the Caring for Our Children: National Health & Safety
Performance Standards (3rd Edition) as outlined in the reference pages.
1) If you have already completed the checklist item, place an X on the line preceding the word, “Completed”.
Provide a brief statement of evidence that demonstrates that the item is completed. For example, “Our facility
tested for radon in 2013 and the results were 3.5.”
2) If you are unable to complete a checklist item, place an X on the line preceding the word “Incomplete”.
3) If you are planning to complete a checklist item should you receive assistance from this mini-grant, place
the requested dollar amount on the line after the words “Cost”.
4) Items 1, 6 and 11 are required. Descriptions must be included that specify how these requirements are being
met.
It is not necessary to complete every checklist item; however please provide a brief explanation of why you are
unable to complete these items. PA Healthy & Green Mini-Grant Application Tips provides samples and
examples on ways to show the status of checklist items.
1. PESTICIDES AND PEST PREVENTION
1.
2.
Completed
Incomplete
Total Cost
We use non-toxic techniques both inside and outside the facility to prevent and control pests (both insects and weeds).
If a serious threat remains and pesticide application is the only viable option, parents and staff are notified in advance
and a licensed professional applies the least toxic, effective product at a time when children will have the least
exposure to the application area for at least 12 hours (see manufacturer’s instructions to ensure 12 hours is enough
time). REQUIRED
Completed
Incomplete
Total Cost
We thoroughly wash all fruits and vegetables to avoid possible exposure to pesticides, and we take the opportunity to
educate children about the importance of doing so
2. AIR QUALITY
3.
4.
Completed
Incomplete
Total Cost
We avoid conditions that lead to excess moisture, because moisture contributes to the growth of mold and mildew.
We maintain adequate ventilation (suitable fans or open screened windows). We repair water leaks and keep
humidity within a desirable range (30-50%).
Completed
Incomplete
We do not allow cars or other vehicles to idle in our designated parking areas.
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Total Cost
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5.
6.
Completed
Incomplete
We do not use scented or unscented candles or man-made air fresheners.
Total Cost
Completed
Incomplete
Total Cost
During operating hours, we do not permit smoking anywhere on the premises or in sight of children. (Note: For the
healthiest environment for children and staff, smoking should not be allowed on the premises at any time).
REQUIRED
3. HOUSEHOLD CHEMICALS
Completed
Incomplete
Total Cost
7. We use unscented, biodegradable, non-toxic cleaning products and least-toxic disinfecting and sanitizing products.
When disinfectants and sanitizers are required, they are used only for their intended purpose and in strict accordance with
all label instructions.
Completed
Incomplete
Total Cost
8. We use chlorine bleach only when and where it is required or recommended by state and local authorities. We use it
prudently and never use more than necessary.
9.
Completed
We do not use aerosol sprays of any kind.
Incomplete
Total Cost
10.
Completed
Incomplete
Total Cost
We use only low-VOC (Volatile Organic Compounds) household paints and do not paint when children are present.
4. LEAD
Completed
Incomplete
Total Cost
11. To avoid possible lead exposure from water lines, we have our water tested. We use only cold water for drinking,
cooking and making baby formula. We run the water for 10-30 seconds or until it feels noticeably colder. REQUIRED
Completed
Incomplete
Total Cost
12. Our facility was built after 1978 — OR — our facility was built before 1978, and we have tested our paint (indoors
and outdoors) for lead. We keep the building free of flaking or peeling paint and regularly wash all areas around doors and
windows. We use lead safe practices when painting or renovating our facility, and we have visited
www.epa.gov/lead to learn more.
Completed
Incomplete
Total Cost
13. To avoid possible lead exposure, we do not use imported, old or handmade pottery to cook, store or serve food or
drinks.
Completed
Incomplete
Total Cost
14. To reduce possible exposure to lead-contaminated dirt, we supply a rough mat at the entrance of our facility and
encourage the wiping of shoes before entering — or — we are a shoe-free facility.
Completed
Incomplete
Total Cost
15. We screen our toys for lead by searching www.cpsc.gov or www.healthystuff.org/departments/toys/ or by
purchasing lead testing kits at a local home improvement store.
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5. MERCURY
16.
Completed
Incomplete
Total Cost
We do not use any mercury-containing thermometers or thermostats. Instead we use digital options.
17.
Completed
Incomplete
Total Cost
We securely store and recycle all used batteries and fluorescent and compact fluorescent light bulbs.
6. FURNITURE AND CARPETS
Completed
Incomplete
Total Cost
18. To avoid possible exposure to flame retardants, we ensure furniture is in good condition without foam or inside
stuffing exposed. Stuffed animals, matting, pillows and other foam items are also intact.
Completed
Incomplete
Total Cost
19. Furniture is made of solid wood or low-VOC (Volatile Organic Compounds) products, with few items made of
particleboard. When purchasing furniture or renovating, we choose either solid wood (new or used) or products that have
low VOCs.
Completed
Incomplete
Total Cost
20. We do not have wall-to-wall carpeting where children are present.
21.
Completed
Incomplete
Total Cost
Area rugs are vacuumed daily and cleaned at least twice a year and as needed using biodegradable cleaners.
7. ART SUPPLIES
Completed
Incomplete
Total Cost
22. We use only non-toxic art supplies approved by the Art and Creative Materials Institute (ACMI). Look for ACMI
non-toxic seal ‘AP’ at www.acminet.org
8. PLASTICS AND PLASTIC TOYS
Completed
Incomplete
Total Cost
23.
23. We avoid toys made out of soft plastic vinyl (such as vinyl dolls, beach balls, and “rubber ducky” chew toys). We buy
only those labeled “PVC-free” and “phthalate-free”.
24.
Completed
Incomplete
Total Cost
When using a microwave, we never heat children’s food in plastic containers, plastic wrap or plastic bags.
Completed
Incomplete
Total Cost
25. We never use baby bottles or sippy cups made with BPA (Bisphenol A). Instead, we use bottles made of glass, or
plastic that is labeled ‘BPA free’.
9. TREATED PLAYGROUND EQUIPMENT
Completed
Incomplete
Total Cost
26. We do not have playground equipment made of CCA treated wood (pre-2006) — or — if we do, we apply 2 coats
of waterproof stain or sealant at least once a year. When building new playground equipment, we only use CCA treated
wood if necessary – and only for the wood touching the ground.
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10. RADON
Completed
Incomplete
Total Cost
27. We have tested our facility for radon. If elevated levels of radon are found, we take action to mitigate. We have
visited www.epa.gov/radon for resources, and have researched state requirements and guidelines to learn more.
11. RECYCLING AND GARBAGE STORAGE
28.
Completed
Incomplete
We recycle all paper, cardboard, glass, aluminum and plastic bottles.
29.
Completed
Incomplete
Total Cost
We keep our garbage covered at all times to avoid attracting pests and to minimize odors.
Total Cost
12. EDUCATION AND AWARENESS
30.
Completed
Incomplete
Total Cost
We create opportunities to educate the families we serve on eco-healthy practices.
OTHER
The Eco-Healthy Child Care Fact Sheet topics listed below are not addressed on the Eco-Healthy Child Care Checklist©. You can
apply for funding to support these items according to the recommendations made in the Eco-Healthy Child Care Fact Sheets©, the
PA Reference Pages for Eco-Healthy Child Care, and the accompanying document called Application Tips. Priority is placed on the
Eco-Healthy Child Care Checklist, but where real need is demonstrated, programs can be awarded funds to support improvements in
these categories. Keep your answers brief and in bulleted format. As above, indicate if the item is incomplete and why, complete, or
the proposed total cost per category and reflect these dollar amounts in your budget summary.
13. ASBESTOS
Completed
Incomplete
Total Cost
14. BUILT ENVIRONMENT
Completed
Incomplete
Total Cost
15. IMPROVING NUTRITION AND
PROMOTING PHYSICAL ACTIVITY
Completed
Incomplete
Total Cost
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