Form CCL.031 "Request for Exception" - Kansas

What Is Form CCL.031?

This is a legal form that was released by the Kansas Department of Health & Environment - a government authority operating within Kansas. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 1, 2020;
  • The latest edition provided by the Kansas Department of Health & Environment;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form CCL.031 by clicking the link below or browse more documents and templates provided by the Kansas Department of Health & Environment.

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Download Form CCL.031 "Request for Exception" - Kansas

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CCL. 031
Kansas Department of Health and Environment
Rev. 8/2020
Bureau of Family Health
Child Care Licensing Program
1000 SW Jackson, Suite 200
Topeka, KS 66612-1274
Phone: 785-296-1270 Fax: 785-559-4244
Website: www.kdheks.gov/kidsnet
REQUEST FOR EXCEPTION
Name of Facility (exactly as stated on the license)
License #
Street Address of Facility
City
Zip Code
County
An exception to a regulation (K.A.R.) may be authorized by the department if:
(1) The applicant requests an exception from the department; and
(2) The exception is determined to be in the best interest of the child or youth and the families.
If you wish to request an exception to a regulation, please provide the following information and return the request to your local child care
facility surveyor. Do NOT send this request directly to KDHE. Incomplete requests or requests not reviewed by the local child care
facility surveyor will be returned and will delay processing. ALLOW A MINIMUM OF 90 DAYS FOR PROCESSING.
Please Print Clearly or Type.
1. I request an exception to the following regulation: K.A.R. 28-4-
.
NOTE: If request is to exceed license capacity, you must complete and attach KDHE form CCL 205, and submit a
supervision plan.
2. I request an exception to (describe fully and include an explanation of why this exception is necessary):
3. Requested Effective Date (may not be prior to the date received by KDHE): (MM/DD/YYYY) ___________________
4. Requested Ending Date (the date you will be in compliance): (MM/DD/YYYY) _________________
5. How is the request in the best interest of the child(ren) or youth and the families?
6. If this exception is granted, how will you assure the health, safety and well-being of children or youth in the facility?
I attest, under the penalty of perjury, that the information on this form is true and correct.
Signature of Authorized Person
Date Completed
Phone #
Email Address
(
)
CCL. 031
Kansas Department of Health and Environment
Rev. 8/2020
Bureau of Family Health
Child Care Licensing Program
1000 SW Jackson, Suite 200
Topeka, KS 66612-1274
Phone: 785-296-1270 Fax: 785-559-4244
Website: www.kdheks.gov/kidsnet
REQUEST FOR EXCEPTION
Name of Facility (exactly as stated on the license)
License #
Street Address of Facility
City
Zip Code
County
An exception to a regulation (K.A.R.) may be authorized by the department if:
(1) The applicant requests an exception from the department; and
(2) The exception is determined to be in the best interest of the child or youth and the families.
If you wish to request an exception to a regulation, please provide the following information and return the request to your local child care
facility surveyor. Do NOT send this request directly to KDHE. Incomplete requests or requests not reviewed by the local child care
facility surveyor will be returned and will delay processing. ALLOW A MINIMUM OF 90 DAYS FOR PROCESSING.
Please Print Clearly or Type.
1. I request an exception to the following regulation: K.A.R. 28-4-
.
NOTE: If request is to exceed license capacity, you must complete and attach KDHE form CCL 205, and submit a
supervision plan.
2. I request an exception to (describe fully and include an explanation of why this exception is necessary):
3. Requested Effective Date (may not be prior to the date received by KDHE): (MM/DD/YYYY) ___________________
4. Requested Ending Date (the date you will be in compliance): (MM/DD/YYYY) _________________
5. How is the request in the best interest of the child(ren) or youth and the families?
6. If this exception is granted, how will you assure the health, safety and well-being of children or youth in the facility?
I attest, under the penalty of perjury, that the information on this form is true and correct.
Signature of Authorized Person
Date Completed
Phone #
Email Address
(
)
MUST BE COMPLETED BY THE LOCAL CHILD CARE FACILITY SURVEYOR:
Child Care Facility Surveyor Recommendation:
Approve: ________
Disapprove: ________
Why?
If recommending approval to exceed license capacity, have you thoroughly reviewed the attached form of enrollment, CCL
205, and verified the child the exception is requested for is also included?
Yes
No
Other Comments:
Signature of Surveyor
Date (MM/DD/YYYY)
County
----------------------------------------------------------------------------------------------------------------------------- ---------------------------------------
MUST BE COMPLETED BY KDHE ADMNISTRATIVE STAFF
Request Returned for the Following Reason:
Form was submitted to KDHE without local surveyor review
Incomplete request
Other (describe):
Request Granted: A review of this Request for Exception and the facility’s compliance history has been completed. The
request is in the best interest of children and families. Based on this review, the request is granted.
Effective Date: (MM/DD/YYYY)
Expiration Date: (MM/DD/YYYY)
Additional Conditions:
KDHE Authorized Signature
Date (MM/DD/YYYY)
Request Denied for the Following Reason:
Granting the request is not in the best interest of children or youth
Granting the request violates Kansas statutes
Facility has a history of noncompliance
Prior exceptions have been granted
Other (describe):
KDHE Authorized Signature
Date (MM/DD/YYYY)

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