West Virginia Code of State Rules
Agency 69 - Health And Human Resources
Title 69 - LEGISLATIVE RULE DEPARTMENT OF HEALTH AND HUMAN RESOURCES
Series 69-05 - Survey Of Facilities For Determinations Regarding Licensure as Residential Child Care Facilities And B
Appendix 69-5 A - FACILITY QUESTIONNAIRE
Answer the following questions:
1. Name of the facility? _________________________________________________
2. The facility is known by what other names? ______________________________
3. Facility Address? ____________________________________________________
4. Name and address of the legal entity operating the facility?
5. Is the facility a public school?____Yes____ No
6. Is the facility a private school?____ Yes____No
6A. Are the school's students exempt from the compulsory attendance requirement of Code § 18-8-1 under that section's "Exemption A. Instruction in a private, parochial or other approved school"? ___Yes____No
6B. Are the school's students exempt from the compulsory attendance requirement of Code § 18-8-1 under that section's "Exemption K. Alternative private, parochial, church or religious school instruction.-? ____Yes____No
7. If the facility is a school, is it accredited by the State Department of Education?
_____Yes_____ No. If yes, attach a copy of a document that verifies accreditation status,
Attach separate sheets as directed with answers to the following questions.
8. Since January 1, 2000, what written or oral communications have come from the facility, its board, staff or the legal entity operating the facility that describe anything that goes on at the facility using the words "treatment" or "therapy?" Describe the recipients, when the communications occurred, and what was meant by "treatment" and "therapy." Include copies of such written communications (names and addresses may be blackened out), including e-mails, advertisements, copies of internet web pages, brochures, pamphlets, etc. if communications are in a form letter, one copy is sufficient.
Answer:____none, or____See attached sheets.
9. What is the range of behavioral problems of the persons served by the facility?
10. For what behaviors or problems is therapeutic intervention provided?
11. Who provides therapeutic intervention?
12. What are the professional qualifications of the persons who provide therapeutic intervention?
13. Since January 1, 2000, what written or oral communications have come from the facility, its board, staff or the legal entity operating the facility that describe anything that goes on at the facility regarding overnight accommodations and services associated therewith? Describe the recipients, when the communications occurred, and any special meaning of the words. Include copies of such written communications (names and addresses may be blackened out) including e-mails, advertisements, copies of internet web pages, brochures, pamphlets, etc. If communications are in a form letter, one copy is sufficient.
Answer:____none, or See attached sheets.
The above answers and any attached statements are true.
_____________________________________________
Signature of the facility's representative.
_____________________________________________
Typed or printed name of the facility's representative.
_____________________________________________
Title of the facility's representative.
Return this Questionnaire and accompanying materials to:
Jim Boggs, Director
Division of Performance and Regulatory Management
Office of Social Services, Bureau for Children and Families
WV Department of Health and Human Resources
350 Capitol Street
Charleston, WV 25301-3704
