City of Chicago Department of Family and Support Services

Facility Assessment
Date
Contact Person:
Name / Title
Facility Info:
Name / Title
1. Are entry area security systems operable? (Lighting, Cameras, Doorbells, Intercoms, Buzzer, etc.)
2. What type of security is in place? (Glass block, security bars, reinforced plexiglass, etc.)
3. Material of exterior entry doors(Wood, Metal, Other): / Problem/Comments (not closing, chipped/peeling, hardware not working, broken/damaged glass, etc.)
4. Is the outdoor play area fenced and secured from public access? If not, explain.
5. Are there childproof locks on the gates and outdoor storage? If not, explain.
6. What is the condition of the play equipment? (broken/damaged equipment, missing equipment, Graffiti, burns or holes on equipment, etc.)
7. What is the condition of the soft surface areas? (damaged/missing areas, uneven distribution of wood chips, shallow depth of wood chips, etc.)
8. Flooring
Room / Dimensions (LxWxH) / Material (Rug, Carpet, Vinyl, Ceramic, Wood, Other) / Problem/Comments (torn carpet, worn carpet, dirty/stained, missing or broken tiles, etc.)
9. Walls
Room / Dimensions (LxWxH) / Material (Drywall, Concrete, Plaster, Other) / Problem/Comments (dirty, peeling/chipping, needs painting etc.)
10. Ceiling
Room / Dimensions (LxWxH) / Material (Drywall, Acoustic Tiles, Other) / Problem/Comments (stained/damaged, peeling/chipping, missing tiles, sagging, etc.)
11. Windows
Room / Dimensions (LxWxH) / Material (Wood, Metal, Glass Block, Other) / Problem/Comments (wind/water leaks, broken/damaged glass, inoperable, damaged/missing shades, gaps, etc.)
12. Doors
Room / Dimensions (LxWxH) / Material (Wood, Metal, Other) / Problem/Comments (not closing, chipped/peeling, hardware not working, broken/damaged glass, etc.)
13. Lighting
Room / Dimensions (LxWxH) / Material (Fluorescent, Incandescent, Other) / Problem/Comments (cracked/broken, not working, missing bulbs, room too dark, etc.)
14. Plumbing
Room / Dimensions (LxWxH) / Fixture (sink, drinking fountain, toilet, etc.) / Problem/Comments (leaks, doesn't work, poor pressure, drain clogged, etc.)
15. Mechanical
Room / Type (Forced Air, Baseboard, Radiators, Unit Vents, etc.) / Problem/Comments (heat not working, air conditioning not working, equipment leaking, room too hot/cold, etc.)
16. Electrical
Room / Do any of the following exist? (Missing cover plates on outlets or switches, missing outlet covers, multiple extension cords, exposed light bulb sockets or wiring, frequent circuit breaker failures, other)
17. Safety
Room / Are following in place? (Exit sign, Evacuation route, Evacuation Procedures, Medical/Dental Emergency Procedures, Smoke Detector, Carbon Monoxide Detector, Fire Extinguisher, Emergency Lighting)
18. Other
Area / Please list any other facility concerns you may have at this site.

Identified Issues/Concerns:

  1. ______
  2. ______
  3. ______
  4. ______
  5. ______
  6. ______

Plan for Resolution (for each issue indicated above):

______

Completion Date: ______

Site Director’s Name (print) ______

Signature: ______

Revised 09/14