The Tennessee Department of Health wants children to be safe and healthy while enjoying their early care and education. Sometimes the past use of a site makes it a poor choice for children. Returning this questionnaire will allow us to look into the environmental history of the site where your child care business is located. This can protect the children, your employees, and your business investment.
This questionnaire collects information about businesses currently located in the same building as your business. An adjacent business could release hazardous materials into the environment that could impact the health of children and employees at your early care and learning business. We are also asking for information about past uses for the property and buildings. Past uses such as manufacturing, industrial or agricultural could have left chemicals behind on the land or in the buildings.
The information you provide will help the Tennessee Department of Health identify whether harmful chemicals may be present at your early learning or day care property. Please answer the questions to the best of your ability going back in time as far as readily available information allows to search for the historical information requested. If, after a reasonable level of effort, you are not able to obtain information about the history of your property, you can check "unknown." More information about our program can be found at tn.gov/ChooseSafePlaces
Email: ChooseSafePlaces.TN@tn.gov
What is your role in the child care business?
* must provide value
Owner/Operator
DHS Pre-Licensure Specialist
Other
If other, please describe:
If you are in the pre-licensure process and have been assigned a Department of Human Services (DHS) Pre-Licensure Specialist, please provide their email address (will end in @tn.gov).
If already licensed by DHS, please type "Already Licensed."
If none of the above or prefer not to respond, please type "NA."
* must provide value
We can send a copy of our response to your DHS Pre-Licensure Specialist to let them know you've completed a Choose Safe Places screening.
Your Name
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Your Phone Number
* must provide value
Your E-Mail Address
* must provide value
Is the person completing the survey different than the contact name above?
Yes
No
Who is completing the survey?
What is your phone number?
Name of Child Care Business
Business Street Address
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Physical address of property (NOT a PO Box or mailing address if different)
Business City
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Adams Adamsville Alamo Alcoa Alexandria Algood Allardt Altamont Ardmore Arlington Ashland City Athens Atoka Atwood Auburntown Baileyton Baneberry Banner Hill Bartlett Baxter Beersheba Springs Bell Buckle Belle Meade Bells Benton Berry Hill Bethel Springs Big Sandy Blaine Bloomingdale Blountville Bluff City Bolivar Braden Bradford Brentwood Brighton Bristol Brownsville Bruceton Bulls Gap Burlison Burns Byrdstown Calhoun Camden Carthage Caryville Cedar Hill Celina Centertown Centerville Central Chapel Hill Charleston Charlotte Chattanooga Church Hill Clarksburg Clarksville Cleveland Clifton Clinton Coalmont Collegedale Collierville Collinwood Colonial Heights Columbia Cookeville Coopertown Copperhill Cornersville Cottage Grove Covington Cowan Crab Orchard Cross Plains Crossville Crump Cumberland City Cumberland Gap Dandridge Dayton Decatur Decaturville Decherd Dickson Dover Dowelltown Doyle Dresden Ducktown Dunlap Dyer Dyersburg Eagleton Village Eagleville East Brainerd East Cleveland East Ridge Eastview Elizabethton Elkton Englewood Enville Erin Erwin Estill Springs Ethridge Etowah Fairfield Glade Fairmount Fairview Fall Branch Farragut Fayetteville Finger Forest Hills Franklin Friendship Friendsville Gadsden Gainesboro Gallatin Gallaway Garland Gates Gatlinburg Germantown Gibson Gilt Edge Gleason Goodlettsville Gordonsville Grand Junction Gray Graysville Greenback Greenbrier Greeneville Greenfield Green Hill Gruetli-Laager Guys Halls Harriman Harrison Harrogate-Shawanee Hartsville Helenwood Henderson Hendersonville Henning Henry Hickory Valley Hickory Withe Hohenwald Hollow Rock Hopewell Hornbeak Hornsby Humboldt Hunter Huntingdon Huntland Huntsville Iron City Jacksboro Jackson Jamestown Jasper Jefferson City Jellico Johnson City Jonesborough Kenton Kimball Kingsport Kingston Kingston Springs Knoxville Lafayette La Follette La Grange Lake City Lakeland Lakesite Lake Tansi Lakewood La Vergne Lawrenceburg Lebanon Lenoir City Lewisburg Lexington Liberty Linden Livingston Lobelville Lookout Mountain Loretto Loudon Louisville Luttrell Lynchburg Lynnville McEwen McKenzie McLemoresville McMinnville Madisonville Manchester Martin Maryville Mascot Mason Maury City Maynardville Medina Medon Memphis Michie Middleton Middle Valley Midtown Midway Milan Milledgeville Millersville Millington Minor Hill Mitchellville Monteagle Monterey Morrison Morristown Moscow Mosheim Mountain City Mount Carmel Mount Juliet Mount Pleasant Munford Murfreesboro Nashville Newbern New Hope New Johnsonville New Market Newport New Tazewell Niota Nolensville Normandy Norris Oakdale Oak Grove Oak Hill Oakland Oak Ridge Obion Oliver Springs Oneida Ooltewah Orlinda Orme Palmer Paris Parkers Crossroads Parrottsville Parsons Pegram Petersburg Philadelphia Pigeon Forge Pikeville Pine Crest Piperton Pittman Center Plainview Pleasant Hill Pleasant View Portland Powells Crossroads Pulaski Puryear Ramer Red Bank Red Boiling Springs Ridgely Ridgeside Ridgetop Ripley Rives Roan Mountain Rockford Rockwood Rogersville Rossville Rural Hill Rutherford Rutledge St. Joseph Saltillo Samburg Sardis Saulsbury Savannah Scotts Hill Selmer Sevierville Sewanee Seymour Sharon Shelbyville Signal Mountain Silerton Slayden Smithville Smyrna Sneedville Soddy-Daisy Somerville South Carthage South Cleveland South Fulton South Pittsburg Sparta Spencer Spring City Springfield Spring Hill Spurgeon Stanton Stantonville Sunbright Surgoinsville Sweetwater Tazewell Tellico Plains Tennessee Ridge Thompson's Station Three Way Tiptonville Toone Townsend Tracy City Trenton Trezevant Trimble Troy Tullahoma Tusculum Unicoi Union City Vanleer Viola Vonore Walden Walnut Grove Walnut Hill Walterhill Wartburg Wartrace Watauga Watertown Waverly Waynesboro Westmoreland White Bluff White House White Pine Whiteville Whitwell Wildwood Lake Williston Winchester Winfield Woodbury Woodland Mills Yorkville Other
Business Zip Code
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Business County
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Anderson County Bedford County Benton County Bledsoe County Blount County Bradley County Campbell County Cannon County Carroll County Carter County Cheatham County Chester County Claiborne County Clay County Cocke County Coffee County Crockett County Cumberland County Davidson County Decatur County DeKalb County Dickson County Dyer County Fayette County Fentress County Franklin County Gibson County Giles County Grainger County Greene County Grundy County Hamblen County Hamilton County Hancock County Hardeman County Hardin County Hawkins County Haywood County Henderson County Henry County Hickman County Houston County Humphreys County Jackson County Jefferson County Johnson County Knox County Lake County Lauderdale County Lawrence County Lewis County Lincoln County Loudon County Macon County Madison County Marion County Marshall County Maury County McMinn County McNairy County Meigs County Monroe County Montgomery County Moore County Morgan County Obion County Overton County Perry County Pickett County Polk County Putnam County Rhea County Roane County Robertson County Rutherford County Scott County Sequatchie County Sevier County Shelby County Smith County Stewart County Sullivan County Sumner County Tipton County Trousdale County Unicoi County Union County Van Buren County Warren County Washington County Wayne County Weakley County White County Williamson County Wilson County Other
Current Property Owner (Street, City, Zip)
Current Property Owner Phone Number
Current Property Owner Address:
Will the child care business be in the same building as other businesses (e.g. in a strip mall or shopping mall)?
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Yes
No
Are any of the following businesses currently operating in the same building/strip mall as the child care business? Check all that apply.
Will the child care business have a separate heating and ventilation system (HVAC) from all other businesses?
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No
Yes
I don't know
Where will the child care business's drinking water come from?
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Municipality (City water, public utility, etc.)
Private well or spring
Unknown
Was the property ever used for any of the following? Check all that apply.
* must provide value
View equation
For any boxes you checked above, please provide as much additional information as possible, including information for more than one type of past use.
Owned/operated during what years?
Provide details about the business including a description of the operation if known.
Owned/operated during what years?
Provide details about the business including a description of the operation if known.
Owned/operated during what years?
Provide details about the business including a description of the operation if known.
Owned/operated during what years?
Provide details about the business including a description of the operation if known.
Owned/operated during what years?
Provide details about the business including a description of the operation if known.
Owned/operated during what years?
Provide details about the business including a description of the operation if known.
Owned/operated during what years?
Provide details about the business including a description of the operation if known.
Owned/operated during what years?
Provide details about the business including a description of the operation if known.
Owned/operated during what years?
Provide details about the business including a description of the operation if known.
Owned/operated during what years?
Provide details about the business including a description of the operation if known.
Since you selected "other" above, please describe the building's or land's other past use(s):
Have any of the following documents ever been prepared for the property? Check all that apply
Are any of the documents/reports available?
Yes
No
Don't know
Please upload reports if available:
Have you seen anything on the child care business property that makes you think harmful chemicals could have been used there in the past? ( For example: metal drums, discarded car parts, construction debris, farm equipment, areas where grass does not grow, concrete or metal plate on the ground covering a hole?)
Yes
No
Don't know
Please provide further details.