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DEPARTMENT OF PUBLIC HEALTH – COMMUNITY SANITATION PROGRAM105 CMR 430.000: MINIMUM STANDARDS FOR RECREATIONAL CAMPS FOR CHILDRENSTATE SANITARY CODE, CHAPTER IVRECREATIONAL CAMP FOR CHILDREN INSPECTION FORMNAME OF CAMP:ADDRESS:OWNER/OPERATOR:OFF SEASON ADDRESS:CAMP DIRECTOR:DATE/TIME OF INSPECTION:PHONE #:TYPE OF CAMP:WATER SOURCE:Day ResidentialSport Non-Sport Medical SpecialtyTrip Primitive/Outpost TravelINSPECTED BY:CAMPER CAPACITY:“No” column marked below indicates a violation of 430.000.“Yes” column marked below indicates compliance with provision of 430.000.“N/A” column marked below indicates that the provision of 430.000 is not applicable to this camp.Regulation – 105 CMR 430YesNoN/ACommentsPERMITSCurrent Certificate(s) of Inspection from local.451building inspector for sleeping/assembly areas.215Written compliance from local fire department.300(A)(2) Private water ).091.159(B)(1).210DEP approval ( 25 people, 60 days/yr)Private water supply: ( 25 people OR 60days/yr)BOH approval, chemical & bacterial analyses, no morethan 45 days prior to openingCAMP POLICIES - WRITTENProcedures for Background Review ofStaff and Volunteers.Staff – CORI and SORIPrevious Work History (5yrs) – 3 Positive Reference ChecksOut-of-state/International Criminal Background ChecksVolunteer Staff – CORI and SORIPrevious Work/Volunteer History (5yrs)Out-of-state/International Criminal Background ChecksAll Background Info - Received, reviewed, & madedetermination required pursuant to .090 (C&D).Staff/Volunteer Orientation: Orientation Plan &Attendance Records, Training on Disaster/EmergencyPlans, Health Care Policies, & Concussion AwarenessAbuse & Neglect Prevention Policies & Procedures.093Report procedures in accordance w/ M.G.L. c. 119, § 51AWritten notification to MDPH and BOH.Discipline Policy: Appropriate Discipline Methods &Prohibitions: (1) Corporal Punishment, includingspanking, is prohibited; (2) No camper shall be.191subjected to cruel or severe punishment, humiliation, orverbal abuse; (3) No camper shall be denied food, water,or shelter; (4) No child shall be punished for soiling,wetting or not using the toilet430-Camp Inspection Form 3-27-18Page 1

Regulation – 105 CMR C).159(B)(2).157(C).190(B)Yes NoCAMP PLANS - WRITTENFire Evacuation Plan and DrillsDisaster/Emergency PlanLost Camper Plan / Lost Swimmer PlanTraffic Control PlanSPECIAL CONTINGENCY PLANS - DAY CAMPCamper doesn’t show up for day.Camper doesn’t show up at point of pick up.Child not registered arrives.Promotional Literature/General RequirementCopy of Policy (Parents/Guardians): Care ofMildly Ill Campers, Administration of Meds &Emergency Health Care Provision.Meningococcal Disease & Immunization infoprovided to parents/guardians annually.Camper released only to Parents/Guardians orDesignated Individual with written authorization.Regulatory Compliance & Licensing Statement:.190(C)“This camp must comply with regulations of the MDPH & belicensed by the LBOH.”.190(D)Inform parents of right to review backgroundcheck, health care, discipline policies and grievanceprocedures upon request.Protocol in place to handle unrecognized persons atcamp.FIELD TRIPSWritten itinerary provided to parents/guardiansbefore departure.Source of emergency care identified; minimum 1health care supervisor accompanying trip.Health records easily accessible for allcampers/staff, medications stored securely andaccessible only by HCS. First aid kit present.Written contingency plans brought on all field trips:(natural disasters, lost camper/swimmer, injuries and illnesses)TRANSPORTATION(at time 250N/A CommentsVehicle must comply with M.G.L. c. 90 §§ 7B & 7D: 14 passengers & driver is camp coach, director, etc.camp vehicles may be used 14 passengers, vehicle must be school busAll vehicles RMV compliant w/ annual safety inspProper automobile insurance.Seatbelts must be worn.1 staff person required when transporting:Campers to the pick-up/drop-off site; or.251(D)(E)8 campers under 5 yrs. of age; or2 campers with physical handicaps.Camper under 7 yrs. are not transported longer than.251(I)1 hour non-stop.Camp vehicle drivers: 18 yrs. , 2yrs. driving.253.251(C).252experience, current license for type of vehicle.First Aid certified if no other trained staff aboard.430-Camp Inspection Form 3-27-18Page 2

Regulation – 105 CMR 430Yes NoSTAFF QUALIFICATIONSN/A CommentsCamp Director:Residential: 25 yrs. , successful completion of Camp.102(A).102(B).102(C).102(D)Administration Course or 2 seasons experience.Day: 21 yrs. , successful completion of CampAdministration Course or 2 seasons experience.Primitive, Travel, Trip: 25 yrs. and proof ofexperience.Designated Substitute:Substitute must meet above criteria.Counselors/Junior Counselors:Day Camp, Non-Sport:.100(C)(2)Counselor 16 yrs. Junior Counselor 15 yrs. .100(A).100(C)(1).100(A)4 weeks experience & attend orientation and trainingResidential, Primitive, Sport, Travel, Trip, Medical:Counselors 18 yrs. or graduated from high schoolJunior Counselors 16 yrs. 4 weeks experience & attend orientation and trainingAll counselors 3 yrs. older than campers.Required Counselor Ratios:Residential / Day / Sports Camps:.101(A)1 counselor per 10 campers 7 yrs. or above1 counselor per 5 campers under 7 yrs.Primitive/Outpost, Travel, Trip Camps:.100(C)(3).101(B).159(C)1 counselor per 10 campers - 1 counselor at least 21 yrs.2 counselor minimum with 1 counselor having First AidCertificate or its equivalentAll Camps:Staffing plan to supervise campers w/ disabilitiesduring regular and specialized high risk activities.Aquatics Director:.020Lifeguard certification, 21 yrs. , 6 weeks previous.103(A) experience in similar supervisory position.Lifeguard:.101(A&B).103.020.103(A)At least 16 years old with [American Red CrossLifeguard Training Cert/Royal Bronze Medallion/BoyScouts Lifeguard Cert/YMCA Lifeguard Cert]* ANDCPR AND First Aid Certificate**Or their equivalentMEDICAL PERSONNELHealth Care Consultant (HCC):MD/DO NP PA (with documented pediatric training).159(A)*Check for Health Care Consultant Agreement*License #:Develop written orders to be followed by HCS,.159(A)(6) including responsibilities for medicationadministrationDevelop a written list of all medication.160(C)administered at campHCC Provided & Documented Trainings:.160(E)(G)(H)HCS required trainings, signs of hypo/hyperglycemia,diabetic plan management, and administering epi-penwith evidence of competency430-Camp Inspection Form 3-27-18Page 3

Regulation – 105 CMR 430Yes NoMEDICAL PERSONNELN/A CommentsHealth Care Supervisor (HCS):(All Camps must have at least 1 HCS on site at all )(D).163.155.154.161(A)MDPANPRNLPN or 18 yrs. , First Aid & CPR certifiedMEDICAL POLICIES AND FACILITIESCamp Health Care PolicyALL Medications stored in Original Containersand meds properly disposed of with disposal log.Meds stored in secured manner (ACA standards)Medication refrigerator temp 36 F - 46 FWritten Medication Administration Policy:Medication administered by HCC authorized staff only;oral/topical medication administration training; andepi-pen and insulin use.Sunscreen policy with parent/guardian sign off.Medical Log:Readily available and signed by authorized staff personInjury Report completed for a fatality or seriousinjury. Copy sent to MDPH and BOH.Day / Residential Camps - Infirmary providedResidential Camps - Easily recognizable andaccessible during the day and night.453.161(B).161(C).140 &.160(F)Lighting provided in infirmary.Residential Camp - Area for isolation of ill childwith ability to provide negative pressure.First Aid Kit: meet ANSI Z308.1-2015 standardsMinimum: 1 Class B kit and 1 Class A kitMedical/Biological waste managed in accordancewith 105 CMR 480.000.MEDICAL RECORDSHealth Record for each Camper & Staff:Staff/Camper 18 yrs: Emergency Contact Info,Written Parental Permission for Meds, Emergency Care,and Self-Administration of epi-pen or insulinCamper 18 yrs: Emergency Contact InfoResidential, Travel, Trip, Sports – Medical History &.151(A)(B) physical within past 18 monthsDay – Medical history signed off by pers and Staff under 18yrs:Number of records checked:.152Campers and Staff over 18yrs:Number of records checked:.152.153Exemption Documentation430-Camp Inspection Form 3-27-18Page 4

Regulation – 105 CMR 430Christian’sLawYesACTIVITIESActivities and physical environment meet the needsof campers; do not pose hazard to health/safety.AQUATICS:Swimming Pool: in compliance with105 CMR 435.000 - Permit PostedCompliant w/ VGB Act & Pool Fence RequirementsBathing Beach: in compliance with 105 CMR445.000 - weekly water sampling, water clarity,and ring buoy presentAll camps in compliance with 105 CMR 432.000M.G.L. c. 111 § 127A ½.204(C).430(B)Swim test to classify swimmers by ability at poolsand beaches (Christian’s Law).190(A).430.432.204(C)NoN/A CommentsProper supervision at swimming venue:.103.204(D)1 lifeguard per 25 campers1 counselor per 10 campersPlan to check swimmers - “buddy system”50 kids in/near water Aquatics Director must be wimming areas clean and safe, no swimming atundesignated sites or at night without lighting.Piers, floats, and platforms in good repair.WATERCRAFTWatercraft: equipped with USCG approvedflotation devices and worn by all campers and staffengaging in watercraft activities.(paddle boards included)White water, hazardous salt/fresh water activities:Campers certified with ARC Level 4 Certificateor equivalent.White water, hazardous salt/fresh water activities:Minimum 2 counselors in separate watercrafts1 counselor per 10 campers (counselor must have lifeguard orsmall craft safety and basic water rescue cert, or equivalent )CRAFTS:.205Equipment in good repair, safety precautions taken.PLAYGROUND/ATHLETIC EQUIPMENT:Equipment properly maintained, fields/surfaces.206(A)(B)free of holes/accident hazards.Playground equipment securely anchored with no.206(C)concrete under/around it, and pliable swing seats.Names/Certs:ARCHERY:.202(A)Equipment in good condition, stored locked.Range away from other activity areas, clearly.202(B)marked danger area with 25 yards clearance behindeach target. Common firing & ready line in place.Personal weapons allowed with camp operator’s.203written permission.103(E)1 counselor per 10 campers at range at all times.430-Camp Inspection Form 3-27-18Page 5