Comments Off on DECONTAMINATION TEMPLATE FOR METHAMPHETAMINE SITES

Epidemiology in North Carolina 

http://epi.publichealth.nc.gov/

 

DECONTAMINATION TEMPLATE FOR METHAMPHETAMINE SITES (North Carolina)

 

 

 

I understand that I must comply with all applicable state and federal laws & regulations.

 

 

I certify that the statements in this decontamination report are true and accurate to the best of my knowledge for property located at

 

________________________________________________________________.

 

 

____________________________________                  ___________

Owner or Responsible Party Signature                                    Date

 

____________________________________               ­­­­­­­­­­­­­    ____________

Contractor (if applicable) Signature                                           Date

 

 

 

 

Contractor information (if applicable):

 

Contractor Company Name: _______________________________

 

Contractor Mailing Address:   ____________________________

 

                                                    ____________________________

                                                    ____________________________

 

Contractor Phone:          _________________________________

 

On-Site Supervisor Name:   _________________________________

 

Worker Name(s):           _____________________________________

       _____________________________________

                                           __________________________________

 

DECONTAMINATION PROCEDURES

 

 

Property Address:  _______________________________

         _______________________________

                              _______________________________

 

 

A detailed description of methods used to reduce contamination.

 

• Date HVAC disconnected: ____/____/______

 

• Date exhaust ventilation with fans initiated: ____/____/______

 

• Date decontamination activities initiated: ____/____/______

 

• Type of personal protective equipment used:

_________________________________________________________

__________________________________________________________

 

• Containerize syringes/drug paraphernalia ________________________

 

• Neutralize chemical spills ___________________________________

 

• Absorb chemical spills and package material _______________________

 

• Remove porous, non-machine washable material(s)

   Carpeting ______________________________________________________

      Location _____________________________________________________

   Upholstered furniture______________________________________________

       Location _____________________________________________________

   Drapery/Curtains (unless machine washable)_________________________

      Location _____________________________________________________

   Other/miscellaneous (i.e. mattresses)

     _____________________________________________________________

     _____________________________________________________________

     _____________________________________________________________

     _____________________________________________________________

     • List items machine washed (two times with detergent) __________________________________________________________

___________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

 

 

 

 

 

• Remove etched or stained plumbing fixtures

    List items removed_______________________________________________

    Location____________________________________________________

 

• Flush attached plumbing ________________________________________________

 

• Remove and replace all HVAC filters _______________________________________

 

• Remove and clean (scrub) HVAC diffusers and intake grills (supplies and returns)

  List detergent used _______________________________________________

 

• Clean (scrub) area around HVAC diffusers and intake grills (supplies and returns)

   List detergent used ________________________________________________

 

• Clean (scrub) interior non-porous ductwork (two feet from the opening)

   List detergent used _______________________________________________

 

• Remove and replace internally insulated ductwork two feet from the opening                 -_______________________________________________________________

___ ____________________________________________________________

 

• Scrub ceiling, walls, floors and other non-porous materials three times

  List areas and items ______________________________________________

   ________________________________________________________________

    ________________________________________________________________

__________________________________________________________________

   List detergent used__________________________________________________

 

• Remaining stained non-porous materials

    Items rewashed   ________________________________________________

    ______________________________________________________________

    Items painted   _________________________________________________

       _____________________________________________________________

     ______________________________________________________________

    Paint product used _______________________________________________

    Location(s) ______________________________________________________

     ______________________________________________________________

    Items discarded ___________________________________________________

    _________________________________________________________________

  __________________________________________________________________

 

 

• Resilient floor coverings (vinyl)

  Cleaned ______ List detergent used ________________________________

     Location(s) __________________________________________________

  Discarded (list areas) ____________________________________________

  Covered in place ____________ Type covering ______________________

    Location(s)______________________________________________________

 

• Ceramic or stone tile surfaces

  Cleaned _________List detergent used _______________________________

      Location(s)___________________________________________________

  Discarded ______List items________________________________________

  Re-glazed ______ Product name ___________________________________

     Location(s) ___________________________________________________

  Grout epoxy-based stained _____Product name__________________________

    Location(s) ________________________________________________

 

• Wooden materials

   Cleaned _____  List detergent used ___________________________________

     List wooden items cleaned________________________________________

     _____________________________________________________________

     Location(s) of wooden items_________________________________________

  Discarded ____ List items____________________________________________

  Sealed with non-water based coating____ Product name ___________________

   Items sealed _____________________________________________________

   Location(s) _____________________________________________________

 

• List appliances removed ______________________________________________

____________________________________________________________________

 

  • Address of waste disposal facility ________________________________________

 

• Date ventilation initiated after decontamination completed: ____/____/______

 

 

Decontamination activity conducted by _______________________________

 Signature _________________________________

 

Date local health department notified of completion of decontamination and provided cleanup activity documentation: ____/____/______

 

 

Retain a copy of receipt(s) for:

    disposal of all items, repairs, purchases of furnishings/appliances/building materials

 

Retain documentation for three years.

 

 

https://epi.publichealth.nc.gov%2foee%2fmeth%2fmeth_decon_template.doc%26ct%3dga%26cad%3dCAcQAhgBIAEoATAKOAJAtdr2iwVIAVgAYgVlbi1VUw%26cd%3dPIHhNTi8Biw%26usg%3dAFQjCNFtmi08iDprbfV9dY3vFDacOMh2dw

 

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