New Jersey Department of Health

Consumer, Environmental and Occupational Health Service

Public Health Sanitation and Safety Program

PO Box 369

Trenton, NJ 08625-0369	YOUTH CAMP SELF‑INSPECTION REPORT

(FOR YOUTH CAMP OPERATORS)
IDENTIFICATION
Camp Name

Permanent Camp ID Number

Name of Owner, Partner or Corporation

Telephone Number

Camp Location Address

GENERAL
YES NO N/A	(Check "Yes" if conforming with provisions of standards; N/A if Not Applicable)
Written job descriptions, disciplinary policy, personnel policies and procedures, emergency procedures for fire, natural disasters, etc., personal data and emergency information for campers and staff, daily health surveillance procedures; lost camper drills and proof of liability insurance.
Name of Insurance Carrier
Policy Number
Expiration Date
Building and grounds maintained in good condition and in compliance with local ordinances and state regulations.
Proper ratio of adults and counselors to campers.
Actual Ratio:	:
Adults/Adult Counselors
Campers
Camp administrator or director meets age and experience requirements.
Name of Camp Director
Age
Years Camping Experience
Appropriate first aid course, bound medical log maintained and staff members instructed in basics of first aid.
Name of Health Director
Health Director’s Certifications
Expiration Date
Name of Directing Physician (if applicable)
Name of Emergency Medical Center
Written health history available for campers and staff.
Emergency drills practiced as required, hazardous substances safely stored, fire fighting equipment readily accessible, and applicable fire safety regulations met.
/ /
/ /
Date of Last Fire Inspection
Date Fire Ext. Last Serviced
Children transported in accordance with Division of Motor Vehicles Services regulations and camp safety standards.
Vehicle Plate Number
Date of Inspection
/
/
/
(If more than three (3) vehicles, attach continuation sheet.)

Camp Name

Permanent Camp ID Number

GENERAL, CONTINUED
YES NO N/A	(Check "Yes" if conforming with provisions of standards; N/A if Not Applicable)
Name of Driver
Type of License
License Expiration Date
/
/
/
(If more than three (3) drivers, attach continuation sheet.)
Sewage and solid waste disposal in accordance with local ordinances and state regulations so as not to create a public health nuisance.
Toilets, lavatories and showers provided and maintained in accordance with local ordinance and state regulations.
Food service and water supply meet the requirements of Chapter XII of the State Sanitary Code and the New Jersey Safe Drinking Water Act.
Date of Last Food Service Inspection
Rating
Date of Last Potable Water Sample
Results (Total Coliform per 100 ml)
Measures taken to assure camp controls fly and mosquito breeding, rodent activity and noxious weeds.
Farm and domestic animals maintained in a manner so as not to create a public health nuisance.
SWIMMING
Swimming pool conforms with Chapter IX, Public Recreational Bathing.
Swimming pool and/or lake bathing waters samples and evaluated for water quality.
Name of Lab Conducting Bacteriological Testing (BT)
Type Disinfectant Used
Date
First BT Test Results
Chemical parameters at time of inspection:
pH
Cyanuric Acid (PPM)
Bromine (PPM)
Free Chlorine (PPM)
Combined Chlorine (PPM)
Other
Swimming area maintained in safe condition, properly delineated based on swimmer ability and lifesaving equipment provided.
Waterfront activities supervised by appropriately certified lifeguard personnel.
Name of Lifeguard
Type of Certification
Expiration Date
/
/
/
(If more than three (3) lifeguards, attach continuation sheet.)
Name of First Aider at Swim Area
Certification
Expiration Date
/
/
SWIMMING, CONTINUED
YES NO N/A	(Check "Yes" if conforming with provisions of standards; N/A if Not Applicable)
First aid equipment provided.
Emergency equipment provided.
Campers tested to determine swimming ability, confined to an area equal to their swimming skill.
Buddy checks conducted every 10 minutes.
HAZARDOUS ACTIVITIES (ARCHERY, RIFLERY, HORSEBACK RIDING, ROPE COURSE, ETC.)
Name of Activity
Name of Adult Specialist
Qualifications
/
/
/
/
/
/
/
BOATING
Watercraft activities supervised by appropriate personnel and all participants wear approved Type I, II or III foam filled Personal Flotation Devices.
Lake boating supervised by adult and an advanced lifesaver patrolling the boating area.
Boating on streams and rivers supervised by adult with demonstrated boating experience (Small Craft Instructor, BSA Aquatics Instructor, educational training or other) and Advanced Lifesaver.
Type I, II or III foam-filled Personal Flotation Devices worn by all boating participants.
Boating activities not conducted in swimming area.
Recommend that a person with at least standard first aid and CPR accompany all out of camp boating trips.
CERTIFICATION
I have reviewed the camp policies, procedures, staffing and physical facilities to determine compliance with the provisions of the New Jersey Youth Camp Safety Act and Standards and I certify that this camp meets these standards.

I realize that I will be liable for a fine not to exceed $1,000 for any violation of the New Jersey Youth Camp Safety Act or of any rule or regulation duly issued thereunto or order issued pursuant thereto.

I certify that the information provided in this report is true, complete and correct to the best of my knowledge and belief.
Name of Person Completing Report (Print or Type)

Title

Signature	Date

YOUTH CAMP SELF‑INSPECTION REPORT (FOR YOUTH CAMP OPERATORS)

(CONTINUED)

CB‑17

FEB 98 Page of 3 Pages.

CB-17

AUG 12	Page 3 of 3 Pages.

AUG 12	Page 1 of 3 Pages.

CB-17, Self-Inspection (for Youth Camp Operators)

CB-17, self-inspection, youth camps, camps and bathing, PHSS,

Ewhite

2012-03-16

NJDOH