DHS - Licensing Inspection Questionnaire

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Licensing Inspection Questionnaire

1.	Type of Program? Family Home Group Home Center
2.	Type of Inspection? New License Renewal 90% Day Interim Complaint
	Other (specify)
3.	Were you at the facility when the onsite inspection was conducted? Yes No Not Applicable
	If yes, are you: The licensee? The licensee designee? Program Director?
	Other Title:
4.	Was the inspection process clearly explained to you by your licensing consultant? Yes No N/A
4a.	Comments
5.	Were you treated professionally by your licensing consultant? Yes No N/A
5a.	Comments
6.	Were your staff and the children in care treated professionally by your licensing consultant? Yes No N/A
6a.	Comments
7.	Did your licensing consultant answer all of your questions? Yes No N/A
7a.	Comments
8.	*If rule violations were identified, were you provided with technical assistance* (TA) to assist you in meeting the requirements of the act and the rules?** Yes No N/A
8a.	Comments
9.	*Were you offered or provided consultation* to assist you in developing methods for improving your program?** Yes No N/A
9a.	Comments
10.	*Are you aware that the TA and Consultation Manual* is available online?** Yes No N/A
10a.	Comments
11.	Did your licensing consultant provide any positive comments on your program? Yes No N/A
11a.	Comments
12.	Were you provided an opportunity to review the inspection findings to clarify incorrect or missing information? Yes No N/A
12a.	Comments
13.	Using the following scale, check the number that applies. The inspection process was helpful to me and accurately assessed my facility's compliance with the rules and the care I provide for children. 1 Strongly Disagree 2 Disagree 3 Neutral 4 Agree 5 Strongly Agree
14.	Any additional comments:
	Name of licensing consultant who conducted the inspection:
	Please provide your contact information.
	Facility Name:
	Would you like someone to contact you? Yes No
	Your Name:
	Your Phone #:
	E-mail Address:
	License #: