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Licensor/Inspection Evaluation Form

Child Care Licensing

All comments are read and appreciated.
For confidentiality purposes, this information will go to the Program Administrator and not to the licensor.

Provider Name (optional):
Type of Facility: Home       Center      
Did the licensor assess compliance only to licensing rules? Yes       No       N/A      
Did the licensor explain the inspection process and any noncompliant items, and answer your questions? Yes       No       N/A      
Approximately Date of Inspection: Calendar
Please enter your feedback here:
If you want us to contact you:
Phone # (000-000-0000)
Best Time of Day to Call:
Email Address ex:

Thank you for helping us improve our program!

May your name be used? Yes      No      

For confidentiality purposes, only the Program Administrator sees your comments.

If you would like a response, please fill out your name and email address.

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