NECPA Verification Visit Request Form for ELCOC Participants

Required Reading to Submit a Visit Request: Verification Visit Scheduling Process

Program Name*

What ELCOC Cohort are you in?

NECPA Site Number (8-Digits)*

Program Director Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Email Address*

State License or Registration Number*

Licensed Capacity*

Number of Classrooms*

Number of Buildings*

Would your program be willing to allow the NECPA to use your verification visit as a training opportunity for NECPA Verifiers?*

Yes
No

Days of Operation*

Select All
Monday
Tuesday
Wednesday
Thursday
Friday

Check all that apply

Hours of Operation*

Verification Visit Request Fee*

Five Block Out Dates

*Block out dates are any days that your program would not be available for a verification visit. You may have five block out days. Days must be listed above in order of preference. The NECPA Office is closed on all federal holidays and will not conduct verification visits on these days.

Please Note: Fees are non-refundable and subject to change without prior notice. All returned checks will incur a $35 fee. As of June 1, 2012 program cancellations, changes to block out dates, requests to place program on hold, and/or refusal of dates are subject to additional fees.

NECPA Process Understandings and Agreements

1) I have answered ALL questions in the yellow AND blue sections of the Self Assessment Instrument.
2) I have collected surveys from at least 70% of my full and part time staff and 50% of the families we serve.
3) In the event that I place my program’s verification status on hold, any changes to NECPA standards and fees will be applicable to the program at the time of reactivation of the verification visit request.
4) I understand that my visit will be scheduled within 120 days (or 60 days if expedited) once the NECPA office receives this form and payment in full.
5) I understand that program cancellations, changes to block out dates, requests to place program on hold, and/or refusal of visit dates are subject to additional fees.
6) I have read the Verification Visit Scheduling Process document provided at the top of this form prior to submitting this request.

Please print your full name to agree to the above NECPA Process Understandings*

Payment Details

Fees are non-refundable and subject to change without prior notice.

Total Amount:

$0.00

NECPA Verification Visit Request Form-ELCOC

NECPA Process Understandings and Agreements

Payment Details