Deficiency Form (5) ALABAMA DEPARTMENT OF HUMAN RESOURCES
CHILD CARE HEALTH & SAFETY GUIDELINES DEFICIENCY REPORT
SECTION A - IDENTIFYING INFORMATION
Facility Name: Type of F ility: Date of Visit
Day
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&v ! Both month/ day / year
Facility Address:&,? �, // Telephone#:
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Acres: Staff in Charge(if applicable): Capacity:
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day / night day / night
SECTION B - DEFICIENCY INFORMATION
Column I Column 2
Health&Safety Guidelines Date Corrected
Deficiency
INSTRUCTIONS TO PERSON IN CHARGE: Cohrntn 2, Date Corrected is to be completed by the facility representative after each
deficiency is corrected The facility representative must put the date of c e t' it and hisAter initials in Column 2. This form must be
returned to the Department of Human Resources on or before , as verification that deficiencies have been
corrected
NOTICE: Any misleading or any false statements or reports made to the Department and/or failure to correct the listed deficiencies can
be the basis for adverse action. None of these requirements are to be interpreted to allow anyone to operate in violation of Health &
Safetv Guidelines. A facility approved by the Department must meet Health&Safety Guidelines applicable to that facility at all times.
It is the responsibility of the facility to erate in compliance wj h Health&Safety Guidelines.
Signature of Facility Representative Date
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Signature of DHR Representative Date
COPIES TO: PageLof l