<p> Child-Caring Agency Contact Information Office of Licensing and Regulatory Oversight</p><p>Child-Caring Agency: Date: </p><p>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.</p><p>Section I. List the contact information for your agency’s executive director, board chair-person and each member of your agency’s governing board.</p><p>Name Title Address Phone Email</p><p>Policy 1-G.4 CF 246A (6/98) Page 1 of 3 Child-Caring Agency:</p><p>Section II. List the contact information for the manager of each individual DHS licensed facility or program within your child- caring agency.</p><p>Manager’s Name Phone E-mail Name and address of facility or program</p><p>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.</p><p>Government Entity Contact Person Address Phone Email</p><p>Policy 1-G.4 CF 246A (6/98) Page 2 of 3 Child-Caring Agency:</p><p>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. </p><p>Brief description of Government Entity Primary Contact Address Phone Email services provided</p><p>Email completed form to [email protected] </p><p>Policy 1-G.4 CF 246A (6/98) Page 3 of 3</p>