Organization Information

*Due to COVID19, all provider inspections will be conducted, by Zoom or Google Meet.

An onsite inspection will be scheduled at a later time.

Date of Inspection: *

Time: *

Green Apple Staff: *

Name of Organization: *

Organization Staff: *

Address: *

City: *

State: *

Zip Code: *

Program Type: *

Full Time Staff: *

Part Time Staff: *

Clients/Students Served: *

Number of Locations: *

License #: *

Date License Expires: *

Licensing Authority: *

Department of Children and Families

Green Apple Accreditation of Children's Services

Oher Oher

Accreditation Process

Outstanding Fees: *

Yes

Self-Study Review (Missing Documents): *

Yes

Comments: *

Follow-up Inspection: *

Announced

Unannounced

Date Date

Recommendation: *

Approval

Deferral

Denial

Due to COVID19, the inspection form will be emailed to the organization staff or representative.

Date:

Organization Staff:

Organization Signature:

clear

Date: *

Green Apple Staff: *

Green Apple Signature: *

clear