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DOH-2040 (12/05) Page 1 of 2 NEW YORK STATE DEPARTMENT OF HEALTH Bureau of Community Environmental Health and Food Protection Children's Camp Written Plan Checklist Dear Camp Operator: Use the following checklist to determine if your written plan addresses the requirements of Subpart 7-2 of the New York State Sanitary Code 7-2.5(n), 7-2.25). Activities not provided by your camp should be checked "N/A" for "Not Applicable." All other items listed, including those already shaded in the “N/A” column, must be addressed in your plan. Please submit the completed checklist with your written plan or plan revision. Camp Name: Date: / / County: Address: Camp Operator Completes Plan Segment Acceptable Required Plan Components Page Yes N/A Local Health Department Remarks Yes No TABLE OF CONTENTS PERSONNEL: Chain of Command Job Description Qualification/Reference Verification FACILITY OPERATION: Water Supply On-Site Sewage Treatment System(s) Lightning Risk Assessment Transportation Housing Food Protection General Operation/Maintenance Waterfront Facility Maintenance FIRE SAFETY: Evacuation Plans; Assembly Area Fire Prevention Electrical Safety Alarm System & Smoke Detectors Fire Extinguishers Exits & Exit Signs Fire Drills and Log Submitted To Local Fire Department MEDICAL PLAN: Duties of Health Director/Personnel Camp Infirmary Description Medication Storage/Administration Universal Precautions Routine Health Care/Surveillance Emergency/Outbreak Procedures Camper Medical History/Screening Existing Health Conditions/Restrictions Medical Log Illness, Injury & Abuse Reporting Camp Sanitation ---PAGE BREAK--- DOH-2040 (12/05) Page 2 of 2 Camp Operator Completes Plan Segment Acceptable Required Plan Components Page Yes N/A Local Health Department Remarks Yes No ACTIVITIES/SUPERVISION: General Supervision; Discipline Passive Activity Supervision Supervision During Rest/Sleep Time Between Activity Supervision Supervision During Transportation Supervision In Emergencies Swimming Buddy System Off-Site & Wilderness Swimming Stream Crossing/Incidental Immersion Boating Horseback Riding Rope/Challenge Course Archery Riflery Out-of-Camp Trips Other Activity Plans STAFF TRAINING: Outline of Curriculum Tour of Camp Description of Camp Hazards Chain of Command Supervision and Discipline Child Abuse Recognition & Reporting First Aid/Emergency Medical Response Injury and Illness Reporting Buddy System Lost Swimmer Plan Lost Camper Plan Out-of-Camp Trips Lightning Plan Fire Safety/Fire Drill Procedures Camp Evacuation Procedures Activity Specific Training Training Attendance Documentation CAMPER ORIENTATION: Outline of Curriculum Tour of Camp Description of Camp Hazards Reporting of Illness & Injury Incidents Buddy System Lost Camper Plan Fire Drills & Evacuation Out-of-Camp Trips Lightning Plan Orientation Attendance Documentation Completed by: Camp Operator Revisions Added by: Camp Operator Local Health Department Reviewed by: Approved: Yes No (circle one) Local Health Department Reviewed by: Approved: Yes No (circle one)