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Copyright © 2019 The NECPA Commission, Inc. NECPA Self Report Form – Cover Sheet NECPA Self Report The purpose of the NECPA Self Report Form is to communicate to the NECPA Commission any licensing violations and/or major changes, which may affect the Accreditation status of a program or ability to comply with NECPA standards. An Accredited program retains a duty to declare certain information within designated timeframes and prior to annual reporting. Failure to submit timely and accurate notification on the NECPA Program Self Report Form may result in immediate revocation of Accreditation status. Program Information Program Name: NECPA Site Number: Director: Owner: Address (Street, City, State, Zip Code): Phone Number: Email Address: NECPA Program Self Report Items (Check all that apply) Programs shall report the following changes and supporting documentation within 72 hours of occurrence to the NECPA Office using the NECPA Self Report Form: SECTION A. Notice of Suspension, Probation, Provisional, Revocation in Licensing Status or Change in License Number Programs shall report the following changes and supporting documentation within 30 days of occurrence to the NECPA Office using the NECPA Self Report Form: SECTION B. Change in Director and/or Administrator SECTION C. Change in Program Name SECTION D. Modification and/or Expansion of Current Building(s) or Grounds SECTION E. Significant Damage to the Building or Outdoor Areas SECTION F. Addition or Reduction of an Age Group SECTION G. Change in Hours of Operation SECTION H. Legal Action and/or Criminal Activity SECTION I. Non-Compliance with NECPA Standard(s) Agreements By submitting this form and its contents to the NECPA Commission, the program certifies the information within this form and all submitted attachments are valid and true. The program understands the NECPA Commission reserves the right to request additional documentation to verify information contained herein and/or determine compliance with the NECPA Standards under which your program was Accredited. Name (Please Print) Signature Date For more information on NECPA news, policies, procedures, amendments and updates, please visit www.necpa.net. Encouraging Quality... Recognizing Excellence. PO Box 2948 Merrifield, VA 22116 1-855-706-3272 phone 1-855-806-3272 fax [email protected] www.NECPA.net

NECPA Self Report€¦ · NECPA Program Self Report Items (Check all that apply) Programs shall report the following changes and supporting documentation within 72 hours of occurrence

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Page 1: NECPA Self Report€¦ · NECPA Program Self Report Items (Check all that apply) Programs shall report the following changes and supporting documentation within 72 hours of occurrence

Copyright © 2019 The NECPA Commission, Inc. NECPA Self Report Form – Cover Sheet

NECPA Self Report

The purpose of the NECPA Self Report Form is to communicate to the NECPA Commission any licensing violations and/or major changes, which may affect the Accreditation status of a program or ability to comply with NECPA standards. An Accredited program retains a duty to declare certain information within designated timeframes and prior to annual reporting. Failure to submit timely and accurate notification on the NECPA Program Self Report Form may result in immediate revocation of Accreditation status.

Program Information

Program Name: NECPA Site Number:

Director: Owner:

Address (Street, City, State, Zip Code):

Phone Number: Email Address:

NECPA Program Self Report Items (Check all that apply)

Programs shall report the following changes and supporting documentation within 72 hours of occurrence to the NECPA Office using the NECPA Self Report Form:

SECTION A. Notice of Suspension, Probation, Provisional, Revocation in Licensing Status or Change in License Number

Programs shall report the following changes and supporting documentation within 30 days of occurrence to the NECPA Office using the NECPA Self Report Form:

SECTION B. Change in Director and/or Administrator

SECTION C. Change in Program Name

SECTION D. Modification and/or Expansion of Current Building(s) or Grounds

SECTION E. Significant Damage to the Building or Outdoor Areas

SECTION F. Addition or Reduction of an Age Group

SECTION G. Change in Hours of Operation

SECTION H. Legal Action and/or Criminal Activity

SECTION I. Non-Compliance with NECPA Standard(s)

Agreements

By submitting this form and its contents to the NECPA Commission, the program certifies the information within this form and all submitted attachments are valid and true. The program understands the NECPA Commission reserves the right to request additional documentation to verify information contained herein and/or determine compliance with the NECPA Standards under which your program was Accredited.

Name (Please Print) Signature Date

For more information on NECPA news, policies, procedures, amendments and updates, please visit www.necpa.net.

Encouraging Quality... Recognizing Excellence.

PO Box 2948 Merrifield, VA 221161-855-706-3272 phone 1-855-806-3272 fax

[email protected] www.NECPA.net

Page 2: NECPA Self Report€¦ · NECPA Program Self Report Items (Check all that apply) Programs shall report the following changes and supporting documentation within 72 hours of occurrence

Copyright © 2019 The NECPA Commission, Inc. NECPA Self Report Form SECTION A

NECPA Site Number:

SECTION A. Notice of Suspension, Probation, Provisional, Revocation in Licensing Status or Change in License Number

Please indicate the following action for your license:

My program’s state license was suspended. Date of suspension:

My program was issued a probationary license. Date of issuance:

My program was issued a provisional license. Date of issuance:

My program’s license has been revoked. Date of revocation:

My program’s license number has changed. Date of change in license number:

Please provide an explanation regarding the above noted change(s):

What is the expected date of conclusion for the above change? N/A

Previous state license number and capacity:

Current state license number and capacity: Same as previous

Required: Please provide supplemental documentation regarding the above changes. Ex: licensing reports, action plans, training logs, etc.

Page 3: NECPA Self Report€¦ · NECPA Program Self Report Items (Check all that apply) Programs shall report the following changes and supporting documentation within 72 hours of occurrence

Copyright © 2019 The NECPA Commission, Inc. NECPA Self Report Form SECTION B-1

NECPA Site Number:

SECTION B. Change in Director and/or Administrator

General Information

Previous Director/Administrator Name:

New Director/Administrator Name:

Email Address:

Start Date:

Date of Birth: *Must be at least 21 years old. Please provide a copy of a valid identification card

Standards edition under which the program is currently accredited:

2009 2017

Director/Administrator Qualifications

Please select at least one criterion from each qualification category for the new Director/Administrator and provide the required documentation for each applicable item.

Administrator Training Safety Certification Education and Experience Continuing Education

National Administrator Credential

(REQUIRED: Provide copy of certificate & résumé)

OR

A course in early childhood administration

(REQUIRED: Provide transcripts & résumé)

OR

At least one year of experience as the administrator of an early childhood program

(REQUIRED: Provide résumé)

Valid certificate in pediatric first aid, including management of a blocked airway, rescue breathing

(REQUIRED: Provide a notarized copy of CPR and First Aid certificates)

BA/BS in child-related field and one year experience in child care with supervisory experience

(REQUIRED: Provide copy of diploma & résumé)

OR

A minimum of 12 credits in early childhood education or development and two years of experience as a teacher

(REQUIRED: Provide transcripts & résumé)

OR

A national competency-based credential such as the CCP or CDA and three years of experience as a teacher

(REQUIRED: Provide copy of certificate & résumé)

*Programs accreditedunder 2017 standardsmust select both itemsin this category.

At least 30 clock hours of job-related continuing education in the first year of employment

(REQUIRED: Complete Section B Training Log with completed and projected continuing education as of the Director’s start date at the program)

AND (ONLY If accredited under 2017 standards)

Documented leadership training

(REQUIRED: Provide copy of certificate and/or agenda that outlines the training topics per page 5 of 90 in the Resource Guide and Standards Book)

Page 4: NECPA Self Report€¦ · NECPA Program Self Report Items (Check all that apply) Programs shall report the following changes and supporting documentation within 72 hours of occurrence

Copyright © 2019 The NECPA Commission, Inc. NECPA Self Report Form SECTION B-2

NECPA Site Number:

SECTION B. New Director Training Logs

New Director Training Report – Completed Trainings

The log below is used to report the new Director's completed continuing education as of the date of hire. Copies of certificates are not required. By submitting this log, the program certifies that the new Director has completed the following training.

Training Topic

Type of Training (Conference, workshop, college class, public school in-service workshop, in-center training)

Date Training Completed

Number of Hours

TOTAL Number of Training Hours

New Director Projected Training Report – Professional Development Plan

The log below is used to report the new Director's plan to complete 30 clock hours of continuing education within one year from the Director’s start date at the program.

*Only use this log if the new Director has not completed 30 hours of training by the time the Self Report is submitted.

Training Topic

Type of Training (Conference, workshop, college class, public school in-service workshop, in-center training)

Date of Upcoming Training

Number of Hours

TOTAL Number of Training Hours

Page 5: NECPA Self Report€¦ · NECPA Program Self Report Items (Check all that apply) Programs shall report the following changes and supporting documentation within 72 hours of occurrence

Copyright © 2019 The NECPA Commission, Inc. NECPA Self Report Form SECTION C

NECPA Site Number:

SECTION C. Change in Program Name

General Information

Program name upon accreditation:

New Program Name:

Date of program name change:

Did your program’s license number and/or status change as a result of this name change?

If your program answered “Yes”, please submit SECTION A in addition to this section. Yes No

Did your program’s name change result as a change in ownership?

If your program answers “Yes”, please also submit the NECPA Change in Program Ownership Form.

Yes No

Please provide further details regarding your program’s name change:

Page 6: NECPA Self Report€¦ · NECPA Program Self Report Items (Check all that apply) Programs shall report the following changes and supporting documentation within 72 hours of occurrence

Copyright © 2019 The NECPA Commission, Inc. NECPA Self Report Form SECTION D

NECPA Site Number:

SECTION D. Modification and/or Expansion of Current Building(s) or Grounds

Please indicate the following action:

Expanded building. Date of expansion:

Conducted major remodeling. Date of remodel:

Modified playground areas. Date of modification:

Other: Date of modification:

Based upon the above response, please provide further details regarding this change:

Addition of resilient surfacing Required: Submit the following supplemental documentation to indicate compliance with the NECPA Standards:

1. Color photograph(s) showing overallmodification

2. Color photograph(s) showing measureddepth of resilient surfacing, if applicable –can be accompanied by service invoiceindicating depth of surfacing installed

3. Color photograph(s) showing measuredperimeter of resilient surfacing, if applicable

*Please see the attached Playground Surfacingand Fall Zones example from the PublicPlayground Safety Handbook developed by theU.S Consumer Product Safety Commission forfurther details regarding requirements.

Modification of resilient surfacing

Addition of playground climbing Equipment

Removal of playground climbing equipment

Addition of playground fencing

Removal of playground fencing

Other:

N/A

Agreement

NECPA Accredited Programs are required to continuously implement the standards under which the program was accredited to ensure an optimal developmental program. Please check the boxes below, indicating agreement to the following items:

These changes/modifications/deletions are in compliance with the current Consumer Product Safety Commission (CPSC) guidelines and the NECPA Standards under which my program was Accredited.*

Based upon the scope and review of the changes and all accompanying documentation, the NECPA Commission may require the program to undergo a verification visit to be paid for by the program.

*To review the current Consumer Product Safety Commission (CPSC) guidelines, please visit www.cpsc.gov. To reviewthe NECPA Standards, please reference your NECPA Standards Book and personalized program profile.

Page 7: NECPA Self Report€¦ · NECPA Program Self Report Items (Check all that apply) Programs shall report the following changes and supporting documentation within 72 hours of occurrence

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Page 8: NECPA Self Report€¦ · NECPA Program Self Report Items (Check all that apply) Programs shall report the following changes and supporting documentation within 72 hours of occurrence

Copyright © 2019 The NECPA Commission, Inc. NECPA Self Report Form SECTION E

NECPA Site Number:

SECTION E. Significant Damage to the Building or Outdoor Areas

Please indicate the item that best describes the damage to the building and/or outdoor areas:

Did this damage occur to:

Flood Interior of facility

Tornado Exterior of facility

Hurricane Both

Fire Other:

Vandalism N/A

Other:

Please provide further details regarding the damage:

As a result of the damage, has your program relocated or closed?

Yes No

If your program answered “Yes” and has relocated, please also submit the NECPA Change in Program Location Form with formal documentation related to the change including the state license. If the program answered “Yes” and has closed, please submit formal documentation related to the closing.

Has this damage caused a disruption to your program’s daily operations?

Yes No

If your program answered “Yes”, please provide further details below:

Did your program’s license number and/or status change as a result of this damage?

Yes No

If your program answered “Yes”, please submit SECTION A in addition to this section.

Page 9: NECPA Self Report€¦ · NECPA Program Self Report Items (Check all that apply) Programs shall report the following changes and supporting documentation within 72 hours of occurrence

Copyright © 2019 The NECPA Commission, Inc. NECPA Self Report Form SECTION F

NECPA Site Number:

SECTION F. Addition or Reduction of an Age Group

Please indicate the age groups served at the time of your last NECPA verification visit:

Please indicate the age groups recently added or reduced in your program:

Birth to 24 months Birth to 24 months Added Reduced

25 to 30 months 25 to 30 months Added Reduced

31 to 35 months 31 to 35 months Added Reduced

3-year olds 3-year olds Added Reduced

4-year olds 4-year olds Added Reduced

5-year olds 5-year olds Added Reduced

6 to 8-year olds 6 to 8-year olds Added Reduced

9 to 12-year olds 9 to 12-year olds Added Reduced

Please provide further details regarding the change

and provide photographs of the classroom(s) for any new age group(s) added using the attached classroom checklists.

Did your program’s license number and/or status change as a result of this addition or reduction?

Yes No

If your program answered, “Yes”, please submit SECTION A in addition to this section with formal documentation related to the change including the state license.

Has your program hired additional NECPA qualified staff members, including lead teachers as a result of this addition or reduction?

Yes No

NECPA Accredited Programs are required to continuously implement the standards under which the program was accredited to ensure an optimal developmental program. Please check the box below, indicating agreement to the following items:

The new age group(s) are supervised by qualified by Qualified Caregivers as defined by the NECPA Commission within your program’s edition of the NECPA Standards Book.

How is your program accommodating the new age group(s)?

Expanded building*

Used empty classroom

Added classrooms*

Merged Classrooms*

Other:

*If your program has modified and/or expanded the building, please submit SECTION D in addition to this section.

Page 10: NECPA Self Report€¦ · NECPA Program Self Report Items (Check all that apply) Programs shall report the following changes and supporting documentation within 72 hours of occurrence

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Page 11: NECPA Self Report€¦ · NECPA Program Self Report Items (Check all that apply) Programs shall report the following changes and supporting documentation within 72 hours of occurrence

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Page 12: NECPA Self Report€¦ · NECPA Program Self Report Items (Check all that apply) Programs shall report the following changes and supporting documentation within 72 hours of occurrence

Cla

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ecpa

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acc

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Page 13: NECPA Self Report€¦ · NECPA Program Self Report Items (Check all that apply) Programs shall report the following changes and supporting documentation within 72 hours of occurrence

Copyright © 2019 The NECPA Commission, Inc. NECPA Self Report Form SECTION G

NECPA Site Number:

SECTION G. Change in Hours of Operation

Please indicate the hours of operation at the time of your last NECPA verification visit:

Please indicate your program’s new hours of operation:

Please provide further details regarding the change in hours of operation:

Did your program’s license number and/or status change as a result of this change in operations?

Yes No

If your program answered, “Yes”, please submit SECTION A in addition to this section.

Has your program conducted fire (evacuation) drills during the following timeframes:

6:00 am and 9:59 am Yes No N/A

10:00 am and 1:59 pm Yes No N/A

2:00 pm and 5:59 pm Yes No N/A

6:00 pm and 11:59 pm Yes No N/A

12:00 am and 5:59 am Yes No N/A

Does your program serve new age groups as a result of this change in hours of operation?

Yes No

If your program answered, “Yes”, please submit SECTION F in addition to this section.

How is your program accommodating the new age group(s)?

Expanded building*

Used empty classroom

Added classrooms*

Merged Classrooms*

Other:

If your program has modified and/or expanded the building, please submit SECTION D in addition to this section.

Page 14: NECPA Self Report€¦ · NECPA Program Self Report Items (Check all that apply) Programs shall report the following changes and supporting documentation within 72 hours of occurrence

Copyright © 2019 The NECPA Commission, Inc. NECPA Self Report Form SECTION H

NECPA Site Number:

SECTION H. Legal Action and/or Criminal Activity

Please indicate the following action:

My program is involved in legal action. My program has reported criminal activity. Other:

Has this legal action and/or criminal activity caused a disruption to your program’s daily operations?

Yes No

If your program answered “Yes”, please provide further details:

Legal Action

Date legal action began:

Date legal action concluded: N/A

What does the legal action concern?

What was the conclusion of the legal action?

Did your program’s license number and/or status change as a result of this legal action?

Yes No

If your program answered, “Yes”, please submit SECTION A in addition to this section.

Criminal Activity

Date criminal activity reported:

What does the criminal activity concern?

What was the conclusion of the criminal activity investigation?

Did your program’s license number and/or status change as a result of this criminal activity?

Yes No

If your program answered, “Yes”, please submit SECTION A in addition to this section.

Programs are required to provide supplemental documentation regarding the above incidents. Please call the NECPA Office directly if you have questions regarding acceptable documentation.

Page 15: NECPA Self Report€¦ · NECPA Program Self Report Items (Check all that apply) Programs shall report the following changes and supporting documentation within 72 hours of occurrence

Copyright © 2019 The NECPA Commission, Inc. NECPA Self Report Form SECTION I

NECPA Site Number:

SECTION I. Non-Compliance with NECPA Standard(s)

Please summarize the standard(s) out of compliance and the date(s) of the violation(s):

Summary examples include: “Handwashing,” Sight and Sound,” “Playground Surfacing,” Teacher Qualifications,” etc.

1. Standard Summary: Date of Occurrence:

2. Standard Summary: Date of Occurrence:

3. Standard Summary: Date of Occurrence:

4. Standard Summary: Date of Occurrence:

5. Standard Summary: Date of Occurrence:

Please provide a detailed narrative regarding the above noted violation(s) and any changes made to achieve compliance:

1. Narrative for Standard Summary:

2. Narrative for Standard Summary:

3. Narrative for Standard Summary:

4. Narrative for Standard Summary:

5. Narrative for Standard Summary:

Programs are required to provide supplemental documentation regarding the above occurrences of non-compliance. Please call the NECPA Office directly if you have questions regarding acceptable documentation.