The Missouri Department of Health and Senior Services has developed the DC 20 form as a vital component for evaluating the regulatory compliance of children's programs in Missouri, underscoring its commitment to maintaining high standards in child care and education. This Program Evaluation Questionnaire serves as a comprehensive tool for gathering essential information about the operational, administrative, and educational facets of child care programs. By requiring a detailed description of the program, parent policies, affiliation with nationally or regionally recognized organizations under Title 36, Public Law 105-225, and specific documentation for religious organizations, the form ensures a thorough review process. Additionally, it seeks to understand the administrative hierarchy within which the program operates by asking for an organizational chart. The questionnaire delves into the operational status, target demographics, operational months, daily schedules, and the financial underpinnings that support the programs' activities, which can range from educational to recreational. This methodical approach not only helps in determining the suitability and compliance of these programs with state regulations but also in ensuring that they meet the necessary standards to provide safe, enriching, and legally compliant services to children. The requirement for signatures from both the director and the administrator of the program cements the accountability and accuracy of the information provided, marking a pivotal step towards achieving regulatory compliance and endorsing quality child care programs.
| Question | Answer |
|---|---|
| Form Name | Missouri Form Dc 20 |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | exempt, affirms, Missouri, 1954 |
Missouri Department of Health and Senior Services Section for Child Care Regulation
Program Evaluation Questionnaire
OFFICE USE ONLY
DVN
INSTRUCTIONS
To determine the regulatory status for children’s programs, the following documents must be submitted with this completed questionnaire:
1.Description of each program(s) or pamphlet describing the program(s).
2.Parent policies, handbook, registration or enrollment form (if available).
3.Documentation from a national or regional Title 36, Public Law
4.For Religious Organizations – A federal tax exemption letter as required by section 501(c)(3) of the Internal Revenue Code of 1954, or any amendment thereto; or documentation that the real estate on which the facility is located is exempt from taxation because it is used for religious purposes or copy of letter of exemption from Missouri sales and use tax on purchases and sales; or documentation that the real estate on which the facility is located is exempt from taxation because it is used for religious purposes; and
Organization chart – This chart must show the structure of the administrative lines of authority between the children’s program(s) and the individual or organization that owns/operates the program(s).
IDENTIFYING INFORMATION (Additional sheets may be attached for each program.)
Name of program
Location of program (street, city, state, zip code)
Mailing address (If different from above.)
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Telephone number of program ( |
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ADMINISTRATION
Organization (or individual) legally responsible for operation and management of the program(s)
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Telephone number ( |
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Contact person (name and title)
Telephone number ( |
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Email Address |
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PROGRAM(S)
Is this program currently in operation?
Yes
No
If no, please show target opening date _____________ and answer the following questions regarding your
proposed plan.
Number of children |
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Age range |
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Months of operation: (Check any that apply.) |
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All 12 months |
January |
February |
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March |
April |
May |
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July |
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August |
September |
October |
November |
December |
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Hours of operation for each program: From |
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a.m./p.m. to |
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a.m./p.m. |
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From |
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a.m./p.m. to |
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a.m./p.m. |
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Maximum number of hours a child may attend each day.
Number of employees’ children enrolled in the program.
Explain how you are compensated for providing your service, this can include any type of funding received?
Does this owner or organization operate any other child care program?
If yes, name and address of program:
Does this program receive any direct state or federal funds? |
Yes |
If yes, list any agencies from which you receive funds: |
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Yes
No
No
Explain what type of activities your program will offer (educational, recreational, childcare, etc.)
SIGNATURES
The undersigned is responsible for the information on this form and affirms that the information is true and accurate. (If the administrator and director are different, the signatures of both individuals are required.)
Name and title of the director of the program (Please print.)
Signature of director of the program
Date
Name and title of the administrator of the organization (Please print.)
Signature of administrator
Date