Child Care Verification of Reopening 2020 UPDATED 6/10/2020
Page 1 of 2
P
lease Indicate the Type of Facility:
_____ Child Care Center/LOC
License #____________________________
_____Family Child Care Home/Large Family
Registration #_______________________
Co
ntact:
Program Name: ____________________________________________________________________________________________________________
Program Address: ________________________________________________________________________________________________________
City: _________________________ State: _________________ Zip code: _______________________
Phone Number: __________________________________________________________
Email Address: __________________________________________________________
C
ontacts of Program
(Please provide information so someone can be reached at any time during operating hours)
Main Contact
Name: _____________________________________________________
Cell Phone Number: __________________________________________________________
Email Address: ____________________________________________________________
Second Contact
Name: _____________________________________________________
Cell Phone Number: __________________________________________________________
Email Address: ____________________________________________________________
Child Care Verification of Reopening 2020 UPDATED 6/10/2020
Page 2 of 2
Please in
itial each item below verifying your understanding and agreement.
_
________ I understand that I must have a current child care center license, letter of compliance, family child care
certificate of registration, or large family certificate of registration.
__________ Family child care homes can ONLY care for the number of children they are licensed for, which is a max of
8 and large family is 12. No group size will be more than 15 with a ratio of 1:14.
__________I will submit a staffing pattern and personnel list to my licensing specialist with this verification form. I
agree and understand that the staff caring for 3 and 4 year olds must be a qualified staff person.
__________I agree to take temperature of ALL children arriving to the building with a temporal thermometer (must
be below 100.4)
__________I agree to limit parent contact by limiting inside access to parents upon drop off or pick up.
__________I agree to practice social distancing the best way possible, within the setting.
__________I agree to virtual or in-person inspections as needed by OCC.
__________I agree to notify licensing specialist and the local health department (LHD) if there are any child, family
member or staff with symptoms of COVID-19 and/or they receive a positive test result. I also agree to follow all
guidance given by the LHD and the regional licensing office.
__________I agree to follow all guidance on the MSDE website.
__________I agree to report all suspected cases and/or positive cases of COVID-19 to the local health department and
the licensing specialist and I will follow all closing guidance given.
__________I understand that not reporting suspected cases and/or positive cases of COVID-19 to the local health
department and the OCC licensing office could result in an action taken against my program that may include
sanctions, emergency suspension and revocation.
ACKNOWLEDGEMENT: I have read or had read to me the terms of the Child Care Verification of Reopening, am
fully aware of the information contained in this document, and understand and agree to the terms.
Name_____________________________________________________ Signature:_________________________________ Date: ____________________
(Please Print)
For Office Use Only: I have reviewed the Child Care Verification of Reopening form with the entity providing this care
and have addressed any questions posed at the time of receipt of the form.
Regional Manager_______________________________________ Signature:_________________________________ Date: ____________________
(Please Print)
D
ate: _________________________________
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