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Deficiency Form (15) ALABAMA DEPARTMENT OF HUMAN RESOURCES CHILD CARE HEALTH& SAFETY GUIDELINES DEFICIENCY REPORT SECTION A-IDENTIFYING INFORMATION Facili ame: Type of Facil' : Date of Visit: Day Night ❑ / Both ❑ month/ day / year Facility Address: /P0 OD Telephone#: Ages: Staff in Charge(f applicable): Capacity: day. / night day / night SECTION B-DEFICIENCY INFORMATION Column I Column 2 Health&Safety Guidelines Date Corrected Deficiency pool- �� lq INSTRUCTIONS-TO PERSON IN C GE: tColumn 2. Date Corrected to-be completed by the facility representative after each deficiency is corrected The facility representative must put the date o recut n his/her initials in Column 2. This form must be returned to the Department of Human Resources on or before 4 •S 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 & Safety 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 operate in compliance with Health&Safety Guidelines. Signature of Facility Representative r Date Signature of DHR Representative Date f COPIES TO: Page L 0 f