Choose Safe Places Minnesota Property Questionnaire

This voluntary questionnaire collects information about the current and former uses of your property and the properties nearby. Your responses will help the Minnesota Department of Health determine whether environmental contamination may be present at your property and provide guidance on actions to take (if necessary) to make sure the property is safe for children and staff. Please complete the questionnaire to the best of your ability.

1. Applicant Contact Information

Name

Phone

Job Title/Role

2. Preferred contact method

Phone
Email

3. Child Care Center Information

Address

Current property owner/contact info

Date building constructed

4. This child care center is:

Not licensed/prospective
Licensed/active

5. Was the property ever used in the past for any of the following?

6. Are properties next door currently used for any of the following purposes?

7. For any checked boxes, please share any known information (name of business, years of operation, type of manufacturing, etc.)

8. Is there anything else you think may be important for us to know about your location?

9. Where does your water come from?

Public water system – municipal
Private well
I don't know

10. Have any environmental assessments been prepared for the property?

Yes, Phase I/Phase II
Yes, Other
No
I don't know

11. Where did you hear about Choose Safe Places Minnesota and the Site Screening Program?

By submitting this property questionnaire, I acknowledge voluntary participation in the Choose Safe Places Minnesota Site Screening Program and acknowledge that I have read the Screening Limitations and Participation Disclaimer on the Site Screening Program website.