AMENDMENT WORK PROGRESS REPORTON LIFE SAFETY SURVEYS/AMENDMENTSDUE ON JUNE 30 THDate:To:From:_______________________SuperintendentSchool District # __________Regional Superintendent of Schools - _____________ CountyIn checking our records, we find that the school building(s) listed below have life safetysurvey/amendments that are not completed. Therefore, these buildings are not in compliancewith the <strong>Health</strong>/<strong>Life</strong> <strong>Safety</strong> Code of Illinois. In order to determine the progress of the life safetywork, it will be necessary for you to complete the information listed below:SchoolBuilding NameOriginalSurvey/Amendment #Itemsin Survey NotCompletedUrgent/Required ItemsNot CompletedApproximateDate ofCompletionNeed Extensionof Time FormStatementof CompletionIf the work cannot be completed by June 30, ______, you must file an EXTENSION OF TIMEapplication with the Regional Office of Education.If the work has been completed, you must submit a STATEMENT OF COMPLETION.If you need either of these forms, contact the Regional Superintendent. Please return this reportto our office as soon as possible.Form 36-23 (3/04) (Prescribed by the Regional Superintendent for the use of the Regional Superintendent) 180.400 b)4-26
STATEMENT OF COMPLETION FORHEALTH/LIFE SAFETY AMENDMENT(Required By 23 IL Administrative Code Part 180)The Board of Education for ______________________________________________________________ , inDistrict Name and Number____________________County, upon resolution adopted at a duly convened meeting, hereby proclaims thework outlined in the <strong>Health</strong> and <strong>Safety</strong> Survey/Amendment # _____________ report for thebuilding at _________________________________________, Illinois, as required under Section 2-3.12 of,Address of Schoolthe School Code of Illinois, approved by the State Superintendent on _________________ in the Amount of $been completed.and with an Actual Expense of $_______________________ , has nowWHEREAS, The <strong>Safety</strong> Survey Report/Amendment described certain conditions of the building that did notcomply with health and safety requirements as set out in Building Specifications for <strong>Health</strong> and <strong>Safety</strong> inPublic Schools, 23 IL ADM Code 185, Efficient and Adequate Standards for the Construction ofSchools, 23 IL ADM Code 175, and/or <strong>Health</strong>/<strong>Life</strong> <strong>Safety</strong> for Public Schools, 23 IL ADM Code Part 180;WHEREAS, The Board of Education of School District No. __________, in _______________________County, has caused to be effectuated such recommendations contained within the <strong>Safety</strong> Survey Report asnecessary to cause compliance with Part 185, 175 and/or 180;NOW, therefore, we __________________________, President of the Board of Education of School DistrictNo. ________in ______________ County, Illinois andarchitect or engineer, state that, the responsiblethe above named <strong>Safety</strong> Survey Report or Amendment is now in compliance with Part 185, 175 and/or 180._____________________________________________________DateSignature of President of the School Board_____________________________________________________(Seal) Date Signature of District Superintendent_____________________________________________________DateSignature of Architect/EngineerThe report of District #_______ has been reviewed. The statements of the Architect and/or Engineer andDistrict Officials provide assurance that all requirements of 23 IL ADM Code, Parts 175, 185 & 180, have beenmet, regarding work at the ________________________________________________________.(Building Name)_____________________DateSignature of Regional SuperintendentForm 36-24 (3/04) (Prescribed by the Regional Superintendent for local board use)4-27County180.400b)
Change language