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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/