Loading...
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: �l �� Day An �/ \_..C�_ \ \ `(X 1 l Gi`� �(e Night ❑❑ Both ❑ month/ day / year Facility Address. �elephone#: y Ages: Staff in Charge(f applicable): Ca aci l C / ni t 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 .j3 ,Zf Signature of DHR Representative Date _ COPIES TO: ._ C7V IN W 1 ���,� l,l Page of