Form Center

2. Surfacing
4. Location*

   1. Aycock
   2. Lions
   3. Oak
   4. Discovery
8. Playground Location
   Describe location of playground at the facility.
9. Surface
10. Age of Intended Users
12. Location of piece
    Describe location of broken piece in detail.
14. Height
18. Does all surfacing material yeaild both a peak deceleration of no more tahn 200 G's and a HIC (Head injury criteria) of no more than 100 when tested in accordance with ASTMI F 1292?*

    1. yes
    2. no
19. Does each peice of equiptment meet the height requirements for each particualr piece of playground equiptment?*

    1. yes
    2. no
21. Comments (Explain in detail)
23. Actions Taken
27. On the swings, is the highest accessible part is the height of the pivot point where the swings suspended elements connect to the supporting structure?*

    1. yes
    2. no
28. On the elevated platforms, is the highest accessible part the height of the platform surface above the playing surface?*

    1. yes
    2. no
29. On the horizontal ladders, is the highest accessible part the maximum height of the structure?*

    1. yes
    2. no
31. On merry go rounds, is the highest accessible part the height above the ground of any part at the perimeter on which a child may sit or stand?*

    1. yes
    2. no
32. On the seesaws, is the highest accessible part is the maximum height attainable by any part of the seesaw?*

    1. yes
    2. no
33. On the spring rockers, is the highest accessible part the maximum height above the playing surface of the seat or designated play surface?*

    1. yes
    2. no
35. On the climbers, is the highest part of the climber intended for foot support?*

    1. yes
    2. no
37. Comments (Explain in detail)
39. Actions Taken
43. On the playground, are there any hard surfacing materials, such as asphalt, or concrete, hard dirt, or soil, grass or turf?*

    1. yes
    2. no
44. Do all unitary materials (rubber mats or rubber like material) have identification of the critical height rating? (This information is to be attained from the manufacturer of the material)*

    1. yes
    2. no
46. Comments (please explain in detail)
48. Actions Taken
52. Are there any loose filled material installed over had surfaces such as asphalt?*

    1. yes
    2. no
53. Do all surface materials pass ASTMI test F 1951?*

    1. yes
    2. no
55. Comments (Explain in detail)
57. Actions Taken
61. Do all landing surfaces meet the requirements according to the ASTMI F 1292 from the maximum fall height?*

    1. yes
    2. no
62. On the stationary equipment, is the use zone extended a minimum of 6 feet in all directions from the perimeter of the equipment?*

    1. yes
    2. no
63. On the slides, does the use zone at the end of the slide extend out a minimum distance of 6 feet or a maximum of 8 feet?*

    1. yes
    2. no
65. On the single axis swings, does the use zone extend to the front and rear of a single axis swing a distance of two times the height of the pivot point above the surfacing material?*

    1. yes
    2. no
66. On multi-axis swings, is the use zone extended in any direction from a minimum distance of 6 feet plus the length of suspended members?*

    1. yes
    2. no
67. On merry go rounds, does the use zone extend a minimum of six feet beyond the perimeter of the platform?*

    1. yes
    2. no
69. On spring rocking equipment, is the use zone extended a minimum of 6 feet from the perimeter of the equipment? Adjacent spring rockers with a maximum seat height of 30 inches may share the same use zone. Rocking equipment meant for standing requires a zone of 7 feet, and use zones may not be shared.*

    1. yes
    2. no
71. Comments (Please explain in detail)
73. Actions Taken
77. Inspection Completed by:*
78. Date:*
79. Time:*
81. Follow Up Inspection
    If a follow up inspection is required, please list date, time and inspector's name here.
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83. 1. Receive an email copy of this form.
84. Email address

    This field is not part of the form submission.

85. Submit

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