OL STAFF - INSPECTION EVALUATION FORM

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OL STAFF - INSPECTION EVALUATION FORM

Please provide feedback to Office of Licensing (OL) in order to improve our processes. All comments are read and appreciated. For confidentiality purposes, this information goes to OL Director and not to the licensor.

Email *

Provider Name (optional):

Would you like us to contact you regarding the information you provided? *

Yes

If you would like us to contact you, please provide your telephone number, your email address and the best time to contact you in the space provided below:

Type of facility: *

Child Care

Human Services

Health Facilities

Other:

Did the licensor assess compliance only to licensing rules or regulations? *

Yes

Not Applicable (N/A)

If you answered "No", please explain:

Did the licensor explain the inspection process, review any noncompliant items, and answer your questions? *

Yes

Not Applicable (N/A)

If you answered "No", please explain:

Approximate DATE of inspection: *

YYYY

Please provide any additional feedback:

May your name be used? *

Yes

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