CCA Contact Information Form

Child-Caring Agency Contact Information Office of Licensing and Regulatory Oversight

Child-Caring Agency: Date:

To comply with ORS 419B and OAR 413-215-0081, 413-215-0091, and 413-215-0096, child-caring agencies must provide the contact information requested on this form. Email the completed form to [email protected] . After submission, provide any updates to the information on this form to your assigned DHS Licensing Coordinator.

Section I. List the contact information for your agency’s executive director, board chair-person and each member of your agency’s governing board.

Name Title Address Phone Email

Policy 1-G.4 CF 246A (6/98) Page 1 of 3 Child-Caring Agency:

Section II. List the contact information for the manager of each individual DHS licensed facility or program within your child- caring agency.

Manager’s Name Phone E-mail Name and address of facility or program

Section II. List the contact information for any governmental agency or unit other than DHS that licenses, certifies, oversees or in some manner regulates your child-caring agency. This may include the Oregon Youth Authority, the Oregon Health Authority, a local county health department, or other regulatory entity whose oversight your agency is subject to.

Government Entity Contact Person Address Phone Email

Policy 1-G.4 CF 246A (6/98) Page 2 of 3 Child-Caring Agency:

Section III. List any governmental agency or unit that has a contract with your child-caring agency to provide care or services to children. Include any government entities located outside of Oregon that contact with your agency.

Brief description of Government Entity Primary Contact Address Phone Email services provided

Email completed form to [email protected]

Policy 1-G.4 CF 246A (6/98) Page 3 of 3