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Deficiency Form ...,r ,. - .. tPa@i s � . - ... �::..� ��.` :u•:�.: '� '«:' --....-. '= _, ..,.�A'�'u,.: .. ..�,a`.�..r.. ._k, a ... DHR-DFC-i 9"(_ ALABAMA DEPARTMENT OF HUMAN RESOURCES 111LD CARE MINIMUM STANDARDS DEFICIENCY REPORT SECTION A- 11)i.NTIFYING INFORMATION Facility Name: 'Type of Facility: Itome n Date of Visit* JULIE CARMACK Tway C 7 Group Ud � Night Q Center C] t / 1 ! Day/Night ® SAT Q month f day ! yea' Facility Address: --- -- Licensee: -- _- - Telephone#: 13000 FRANKFORT ROAD JULIE CARMACK f2561702-3600 TUSCUMBIA,AL 35674 Ages: Director(if applicable): Capacity: 6 Weeks through 13 Years 12 -Day 6 Weeks through 13 Years 8 - Day/Night SECTION B -DEFICIENCY INFORMATION Column I Column 2 Minimum Standard Date Corrected by Deficiency Licensee 1 " 03 INSTRUCTIONS TO LICENSEE: Column 2, Date Corrected by Licensee, is to be completed by the facility representative after each deficiency is corrected The facility representative must put the date of correction and his/her initials in Column 2. This form must be returned to the Department of Human Resources on or before,,-'4-LA,C,�i < ,£- as verificatioir drat deficiencies have been corrected NOTICE: Any misleading or any false statements or reports made to the Department and/or failure to correct the liste, deficiencies can be the basis for adverse action. None of these requirements are to be interpreted to allow anyone to operate i violation of Minimum Standards. A facility licensed by the Department must meet Minimum Standards applicable to that facilit. all times. It is the responsibility of the licensee to operate in compliance with Minimum Standards. ,Signature of Facility Representative __-Date t Signature of DHR Licensing Representati vw-- Date 7 t COPIES TO: j-gti'e i E-MAIED AUG - 120 a* c tccticat report for t o ions giving; Are to ct 1drea x tt. I)tttZ-Gi3C 7 37 . MEDICAL REPORT FOR PERSONS GVVING CARE TO CH C.UREN ` Name: It � �t Y 11 (,� Date of birth: position in child care facility: Address: ` tll"Ylhl kt_." �� o w G� To the ezannining In doctor,physician's assistant,or certified nurse practitioner; This examination is needed to determine my physical ability to care for children, to x .. dity, or to have contact with perform services in a child care fac the children. I hereby authorize you to furnish a report of my examination to: — Name of child care facility or Dep nt of Human Resources Date Signature TESTS(to be completed if other verification is not attached): Date and result OfIntradermal Tuberculin Test(Mantoux): (Required for initial examination only) Date and.result of chest x-ray if Manton'was positive: chronic disease or disability that may affect his/her ability to care for children or HISTORY of any Yes ❑; No �I: perform services in a child facility: PHYSICAL IMITATIONS that may affect his/her ability to care for children or perform services in a child care facility: Yes ❑; No ®. If"YES",please explain: In my opinion, the physical examination reveals that the above-named person freesery f in a any infectious or contagious disease and is physically fit to care for children, to perform child care facility or to have contact with the children- If not,please explain: � ate S' atdene medical or,F ysici�tnIs assistant,or certified nurse practitioner I 64 a,; 4 November 30.201s E—MAILED AUG — 12D2Q