REOPENING REQUEST FORM – Family Child Care and In-Home Providers
Program Type
*
Family Child Care Provider
In Home Child Care Provider
Name of Storm
*
Parish
*
TIPS Number
(If applicable)
Provider Name
*
Email Address
*
Provider Physical Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Provider Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Section 1:
Please check one of the following statements below:
*
This home DID NOT sustain damage and was able to continue operation.
This home DID NOT sustain damage and is expected to reopen.
This home DID sustain minimal damage and is expected to reopen.
This home DID sustain major damage and is expected to reopen.
This home did sustain damage and WILL NOT REOPEN.
Effective Operation Date:
-
Month
-
Day
Year
Date
Expected Reopening Date:
-
Month
-
Day
Year
NOTE: If reopen date changes, contact your Licensing Consultant.
Effective Closure Date:
-
Month
-
Day
Year
Date
Section 2:
Did the home sustain any major structural damage to include fence?
Yes
No
Describe type of damage:
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Are all utilities (water, sewages, electricity) currently operating normally?
Yes
No
Was electricity off for more than 48 hours? (Note: If yes, it is your responsibility to destroy and dispose of any food or food items properly.)
Yes
No
If the home lost electricity, has electricity been restored by the electric company?
Yes
No
N/A
Is the home operating on generator power?
Yes
No
Is your home located in an area that was subject to a boil advisory?
Yes
No
Did any flood water enter the home? (Note: If yes, it is your responsibility to destroy and properly dispose of any items that came into contact with flood waters.)
Yes
No
Is there any visible mold in your home or has your home been treated for mold remediation?
Yes
No
Is the fire alarm system working?
Yes
No
Are the smoke detectors working?
Yes
No
Do you have a sprinkler system?
Yes
No
If you have a sprinkler system, it is in working order?
Yes
No
N/A
Are the exits free and unobstructed?
Yes
No
Are the exit doors in proper working condition?
Yes
No
Additional Comments:
Section 3:
Who completed the form?
*
Owner
Other
Submit
Should be Empty: