HomeMy WebLinkAboutDeficiency Form (20) ALABAMA DEPARTMENT OF HUMAN RESOURCES
CHILD CARE HEALTH & SAFETY GUIDELINES DEFICIENCY REPORT
SECTION A-IDENTIFYING INFORMATION
Facility Name: Type of Facility: Date of Visit:
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Both ❑ month/ day / year
Facility Address. �elephone#:
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Ages: Staff in Charge(f applicable): Ca aci
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day / night
SECTION B-DEFICIENCY INFORMATION
Column t
Health&Safety Guidelines Column 2
Date Corrected
Deficiency
INSTRUCTIONS TO PERSON IN CHARGE: Column 2, Date Corrected is to be completed by the facility representative after each
deficiency is corrected The facility representative must put the date of rrecdon and his/her 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.
*Hazards must be cor4d immediately
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 Date
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Signature of DHR Representative Date _
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