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picture1_Agreement Sample 202312 | Bpa 2011 Paper


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File: Agreement Sample 202312 | Bpa 2011 Paper
child care business partnership agreement dear child care business owner director please read and sign the following agreement prior to the visit by your child care nurse consultant i look ...

icon picture PDF Filetype PDF | Posted on 10 Feb 2023 | 2 years ago
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                                        Child Care Business – Partnership Agreement                                           
              
             Dear Child Care Business Owner/Director: Please read and sign the following agreement prior to the visit by your 
             Child Care Nurse Consultant. I look forward to working with you to improve the health and safety of children 
             enrolled in your care. Thank you.  
             Child Care Nurse Consultant name: ___________________________________ Telephone: _________________ 
              
             Name of Child Care Business: ____________________________________________________________________ 
             Name of Owner/Director: _______________________________________________________________________ 
             Mailing Address: _____________________________________ City: ___________________ Zip Code: ________ 
             Street Address if different than mailing address: ______________________________________________________ 
             Telephone Number: _____________________________ Fax Number: ___________________________________ 
             Email Address: ________________________________________________________________________________ 
              
             Type of Business (Check ALL boxes that apply.):    Start-Up (in business less than 90 days) 
                DHS Licensed Child Care Center      DHS Licensed Preschool      Head Start or Early Head Start  
                Shared Visions Preschool     School-Based Child Care Center     School-Based Preschool 
                In-Home Non-Registered 
                DHS Registered Child Development Home: In what level/category of child development home are you registered? 
                     Registration Level:    A      B       C 
                Other; please specify: _________________________________________________________________________________ 
              
                                      Authorization for Child Care Nurse Consultant Services* 
              
             I (we), _______________________________________________ authorize the Child Care Nurse Consultant 
              
             ________________________________ to provide health and safety consultation. I (we) have been informed and 
                      
             consent to the consultation services which could include, but are not limited to, the following activities: 
              
                Direct observation of learning environments indoors and outdoors 
                Observation of practices carried out by personnel (example: diapering, feeding, sanitizing, supervision) 
                Review of health and safety written policies                                                                              Name
                Review of parent consent forms pertaining to health and safety of children 
                                                                                                                                            
                Review of daily medication record forms                                                                                   of 
                                                                                                                                           B
                Review of child injury/incident report forms                                                                              us
                                                                                                                                           i
                Review of health and safety regulatory records                                                                            ne
                                                                                                                                           s
                Assessment of safety hazards indoors and outdoors                                                                         s
                                                                                                                                           :
                                                                                                                                            
                Review and assessment of child and personnel immunization certificates                                                    __
                Review and assessment of child health exam forms and parent statements                                                    __
                                                                                                                                           _
                Review and assessment of employee, substitutes, and volunteers health exam or personal health statement                   _
                 forms                                                                                                                     __
                                                                                                                                           __
                Other assessment (specify) _______________________________________________________________                                __
                                                                                                                                           _
             Owner or Director Signature(s) _______________________________________________________________                                __
                                                                                                                                           _
             Date ___________________                                                                                                      __
                                                                                                                                           __
                                                                                                                                           _
             Child Care Nurse Consultant Signature _________________________________________________________                               __
             Date___________________                                                                                                       _
                                                                                                                                           __
             *This authorization is in effect for two calendar years from the date of Owner/Director’s signature.                           
                                                                                                                 FORM #: HCCI-BPA2011 
              
The words contained in this file might help you see if this file matches what you are looking for:

...Child care business partnership agreement dear owner director please read and sign the following prior to visit by your nurse consultant i look forward working with you improve health safety of children enrolled in thank name telephone mailing address city zip code street if different than number fax email type check all boxes that apply start up less days dhs licensed center preschool head or early shared visions school based home non registered development what level category are registration a b c other specify authorization for services we authorize provide consultation have been informed consent which could include but not limited activities direct observation learning environments indoors outdoors practices carried out personnel example diapering feeding sanitizing supervision review written policies parent forms pertaining daily medication record injury incident report us regulatory records ne s assessment hazards immunization certificates exam statements employee substitutes vo...

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