Deficiency Form (15) ALABAMA DEPARTMENT OF HUMAN RESOURCES
CHILD CARE HEALTH& SAFETY GUIDELINES DEFICIENCY REPORT
SECTION A-IDENTIFYING INFORMATION
Facility Name: Type of Facility: Date of Visit:
Day ❑
Night Elago /
Both ®�� month/ day / year
Facility Address: kl) Telephone#:
Ages: Staff in Charge(if applicable): Capacity:
day / night day / night
SECTION B-DEFICIENCY INFORMATION
Column 1
Column 2
Health&Safety Guidelines
Date Corrected
Deficiency
n r
4-9- 19�
r
4-9 .1 958
^ 56
4_9_I 5-
INSTRIXTIONS TO PERSON.IN_ _ _GE Column 2. Date Corrected is to be completed the-facility representative after each
defcien_ey-is-corrected The facility representative must put the date correction d h' er initials in Column 2: . Tiiis`joTm must'be
,rrned to_the�Department o Human Resources on o'r bejore as v`erific tion that deficiencies haoe be n
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 &
Safety Guidelines. A facility approve by the Department must meet Health&Safety Guidelines applicable to that facility at all times:
It is the responsibility of the facility t o crate in compliance with Health&oSafety Guidelines.
Facility Representative 6"`-'�' Date b - ,
Signature of F ity R p
Signature of DHR Representative `'%(/ram Date
COPIES TO: Page of/