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TEN-YEAR SAFETY SURVEY REPORTVIOLATION AND RECOMMENDATIONSCHEDULE(23 IL Adm. Code 180, Sections 180.320)For ISBE Use:ISBE review recommendationshave been discussed with the A/E.___________ _____________Date Reviewer Initials1. COUNTY CODE 2. DISTRICT CODE/NAME 3. SITE CODE 4. FACILITY CODE/NAME5. ITEMI.D.6. LOCATION (S)(ROOM No.)7. PRIORITYCODE8. RULE VIOLATED 9. DESCRIPTION OF THE VIOLATION 10. RECOMMENDATION TO CORRECT VIOLATIONForm 35-84 (3/04) (Prescribed by ISBE for local board use) 180.320 c) 2)THIS IS PAGE ____ OF ____ PAGES3-7
Form 35-84 (3/04)INSTRUCTIONS FOR COMPLETINGTEN-YEAR SAFETY SURVEY REPORTVIOLATION AND RECOMMENDATION SCHEDULE1. COUNTY CODE/NAME. Enter the county name and the 3 digit county number taken from the ISBE Directory of Illinois Public Schools, PublicSchool Districts and other Education Units.2. DISTRICT CODE/NAME. Enter district name and the 4-digit district number taken from the ISBE Directory of Illinois Public Schools, Public SchoolDistricts and other Education Units.3. SITE CODE. Enter the 3-digit number assigned by the Regional Superintendent.4. FACILITY CODE/NAME. Enter the name of the building or structure and the 3-digit facility number assigned by the REGIONALSUPERINTENDENT.5. ITEM I.D. Enter the number to identify the violation found during the inspection.6. LOCATION(S). Specify the location(s) where the violation is found.7. PRIORITY CODE. Enter the priority that best describes the degree of hazard the problem creates:a. Urgent identify items that present an immediate hazard to the safety of students and reference specific rules in the code that are applicable tothe building. These items must be corrected within one year.b. Required identify items that are necessary for a safe environment but present less of an immediate hazard to the safety of students andreference specific rules in the code that are applicable to the building. These items must be corrected within five years.c. Recommended identify items that do not present any immediate hazard to the students and do not reference any specific rule in the code thatare applicable to the building as authorized by ILCS 5/17-2.11. These items are not required by code. Examples of recommended items are:energy conservation; security; repair of school sidewalks, playgrounds, parking lots, or school bus turnarounds; and accessibility.8. RULE VIOLATED. Specify the rule number in the code that is applicable to the facility where the violation is found, as stated in Section 180.60.Example: Fire alarm systems are not functioning properly - specify section 185.395d, section 175.470 or section 918, the applicable rule usedwhen the building was built.9. DESCRIPTION OF VIOLATION In a clear and concise manner, describe the violation10. RECOMMENDATION TO CORRECT VIOLATION. Describe the corrective measure to the rule violated in item 9 above.3-8
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Health/LifeEffectiveMarch 20042 nd
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FOREWORDThe information in this pub
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TABLE OF CONTENTSForeword----------
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• Application for Extension of Ti
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School Building Construction/Recons
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CHAPTER 1FORMS• Application for B
Page 13 and 14: Pre-Construction Plans and Specific
Page 15 and 16: Regional Superintendent’s Verific
Page 17 and 18: SCHOOL BUILDING PERMITREGIONAL OFFI
Page 19 and 20: ______________________________ COUN
Page 21 and 22: PARTIAL FACILITY OCCUPANCY RESTRICT
Page 23 and 24: Annual Building InspectionOverviewT
Page 25 and 26: CHAPTER 2FORMS• Notice of Annual
Page 27 and 28: HEALTH/LIFE SAFETY ANNUAL INSPECTIO
Page 29 and 30: Y N NA Boiler Room(s) 175 185 180 R
Page 31 and 32: Y N NA Music Practice Room 175 185
Page 33 and 34: HEALTH/LIFE SAFETY CHECKLIST/GLOSSA
Page 35 and 36: 23. Hold-Open Devices (185.370b11A;
Page 37 and 38: 52. Door Closers (185.390e2E; 185.3
Page 39 and 40: 72. Door Closers (185.380c10E; 185.
Page 41 and 42: GREENHOUSE121. Fire Detectors (185.
Page 43 and 44: 153. Hold-Open Devices (185.370b11A
Page 45 and 46: 185. Illuminated Exit Signs (185.37
Page 47 and 48: 228. Flammable Storage (185.370b4H;
Page 49 and 50: 263. Hold-Open Devices (185.370b11A
Page 51 and 52: 312. Door Closers (185.380c10E; 185
Page 53 and 54: GLOSSARYNUMBERLOCATION(i.e. Fire Ar
Page 55 and 56: Posted Occupancy NoticeNOTICEFOR YO
Page 57 and 58: REGIONAL SUPERINTENDENT’S ANNUAL
Page 59 and 60: OVERVIEW OF TEN-YEAR SURVEY PROCESS
Page 61 and 62: CHAPTER 3FORMS AND DOCUMENTS• App
Page 63: CERTIFICATE OF BUILDING COMPLIANCE(
Page 67 and 68: 5) Utility supply services (water,
Page 69 and 70: SAMPLE 10-YEAR SURVEY REPORT(To be
Page 71 and 72: paneling on stud walls with either
Page 73 and 74: water converter to heat these secti
Page 75 and 76: X. LEAD-BASED PAINT Peeling paint w
Page 77 and 78: NOTICE OF INCOMPLETE SAFETY SURVEY
Page 79 and 80: CHAPTER 4HEALTH/LIFE SAFETY AMENDME
Page 81 and 82: State Superintendent on the Approva
Page 83 and 84: Step #4The state superintendent che
Page 85 and 86: Procedures for Health/Life SafetyEm
Page 87 and 88: HEALTH/LIFE SAFETYCERTIFICATE OF AU
Page 89 and 90: Fire Prevention and Safety Funds--E
Page 91 and 92: CHAPTER 4FORMS AND DOCUMENTS• Eme
Page 93 and 94: CERTIFICATION OF NEED FOR FIRE PREV
Page 95 and 96: Instructions for CompletingSchedule
Page 97 and 98: Instructions for CompletingRecommen
Page 99 and 100: REGIONAL SUPERINTENDENT’S CERTIFI
Page 101 and 102: ORDER TO EFFECT COMPLIANCE WITH THE
Page 103 and 104: This application is to befilled out
Page 105 and 106: STATEMENT OF COMPLETION FORHEALTH/L
Page 107 and 108: REGIONAL OFFICE OF EDUCATIONAPPLICA
Page 109 and 110: Sample wording for notices of publi
Page 111 and 112: CHAPTER 5TEMPORARY FACILITIES• Te
Page 113 and 114: Temporary vs Permanent Facility Pro
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Application for Approval for Use of
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c c c 29. Is the insulation materia
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CHAPTER 6CONDEMNATION/DEMOLITION PR
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ORDER OF CONDEMNATIONDISTRICT NAME
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DISTRICT NAMEFACILITY NAMEAPPLICATI
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cccccc9. Removal of debris:Verify t
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Code InformationWhen are Part 180,
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Reference List of Codes for Public
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Asbestos Abatement for Public and P
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The Illinois Water Well and Pump In
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ARTICLE 14. CHILDREN WITH DISABILIT
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