NECPA Verification Visit Request Form

The purpose of this form is to notify the NECPA Commission that your program has completed the self-study portion of the NECPA accreditation process and that you are ready to begin scheduling your verification visit. PLEASE SUBMIT THIS FORM TO SCHEDULE A VERIFICATION VISIT.

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

Program Name*

NECPA Site Number (8-Digits)*

Program Director Name*

First Last

Email Address*

State License 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

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 re-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 re-verification visits on these days.

Would You Like to Purchase Additional Block Out Dates?

Yes
No

Additional Block Out Date Fee

Price: $27.50

Pricing is per EACH additional block out date.

How Many Block Out Dates Would You Like to Purchase?

Please List Your Additional Block Dates Requested:

Would You Like to Expedite Scheduling to Reduce Scheduling Window?

Yes
No

Expediting this process will shorten your scheduling window from 120 days to 60 days.

Expedited Scheduling Fee

Price: $550.00

Expediting this process will shorten your scheduling window from 120 days to 60 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.

Agreements

1) I have answered each question in the yellow and blue sections of the Self Assessment Instrument or given a written explanation in the comment section if the question is not applicable to my program.
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 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 Name To Agree To The Stipulations*

Payment Details

Total Amount:

$0.00

Credit Card

American Express

Discover

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name