Form OCC1268 "Environmental Health Survey" - Maryland

What Is Form OCC1268?

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

Form Details:

  • Released on July 1, 2005;
  • The latest edition provided by the Maryland State Department of Education;
  • 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 OCC1268 by clicking the link below or browse more documents and templates provided by the Maryland State Department of Education.

ADVERTISEMENT
ADVERTISEMENT

Download Form OCC1268 "Environmental Health Survey" - Maryland

Download PDF

Fill PDF online

Rate (4.4 / 5) 37 votes
Page background image
MARYLAND STATE DEPARTMENT OF EDUCATION
Office of Child Care
ENVIRONMENTAL HEALTH SURVEY
THIS SECTION TO BE COMPLETED BY THE APPLICANT
Name of Provider/Facility:
Address of Provider/Facility:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Phone Number:
County:
Number living in Family Child Care Home:
(do not include provider’s own children under 6 years of age)
Requested Capacity
: (maximum number of children at any time including provider’s own children under 6 years of age)
PUBLIC
PRIVATE
PUBLIC
PRIVATE
Sewage Disposal:
Water Supply:
THIS SECTION TO BE COMPLETED BY LOCAL HEALTH DEPARTMENT
In Compliance
Not in Compliance
Findings:
Water Supply:
Sewage Disposal:
Recommendation:
License/Register
License/Register with plan to correct
Do not License/Register
Emergency Suspension because of imminent risk to children
Comments: ____________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
_________________________________________ ____________
__________________________________ _________________
Health Department Inspector Signature
Date
Health Officer Representative Signature
Date
Return completed form to: ________________________________________________________ by: ____________________________
OCC 1268 (Revised 7/05) All previous editions are obsolete.
MARYLAND STATE DEPARTMENT OF EDUCATION
Office of Child Care
ENVIRONMENTAL HEALTH SURVEY
THIS SECTION TO BE COMPLETED BY THE APPLICANT
Name of Provider/Facility:
Address of Provider/Facility:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Phone Number:
County:
Number living in Family Child Care Home:
(do not include provider’s own children under 6 years of age)
Requested Capacity
: (maximum number of children at any time including provider’s own children under 6 years of age)
PUBLIC
PRIVATE
PUBLIC
PRIVATE
Sewage Disposal:
Water Supply:
THIS SECTION TO BE COMPLETED BY LOCAL HEALTH DEPARTMENT
In Compliance
Not in Compliance
Findings:
Water Supply:
Sewage Disposal:
Recommendation:
License/Register
License/Register with plan to correct
Do not License/Register
Emergency Suspension because of imminent risk to children
Comments: ____________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
_________________________________________ ____________
__________________________________ _________________
Health Department Inspector Signature
Date
Health Officer Representative Signature
Date
Return completed form to: ________________________________________________________ by: ____________________________
OCC 1268 (Revised 7/05) All previous editions are obsolete.