Form DHS969 "Child Care Licensing Self-certification Form" - Hawaii

What Is Form DHS969?

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

Form Details:

  • Released on February 1, 2001;
  • The latest edition provided by the Hawaii Department of Human Services;
  • 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 DHS969 by clicking the link below or browse more documents and templates provided by the Hawaii Department of Human Services.

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Download Form DHS969 "Child Care Licensing Self-certification Form" - Hawaii

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State of Hawaii
Benefit, Employment & Support Services Division
Department of Human Services
CHILD CARE LICENSING SELF-CERTIFICATION FORM
Date:
Name of Child Care Center:
Address:
Phone:
Please attach the center’s completed Child Care Center Staff and Volunteer Listing (DHS 954)
and Staff Sequence Form (DHS 957) which should contain the most current information.
I certify the following:
1)
All staff listed on the attached Child Care Center Staff and Volunteer Listing form
qualify for the positions that they hold. This complies with the applicable child care
licensing rules, for Group Child Care Centers and Group Child Care Homes (17-892.1-
17), for Infant and Toddler Child Care Centers (17-895-16), or for Before and After-
School Child Care Centers (17-896-16).
2)
The staff-child ratios and staff-employment sequence for this center is met and
maintained at all times and in compliance with the child care licensing rules (§17-892.1-
18, §17-895-17 & §17-895-18, or 17-896-17) that apply to this center.
3)
The employment history clearances have been completed for all staff listed on the
attached Child Care Center Staff and Volunteer Listing form.
Name:
Title:
Signature:
DHS 969 (2/01)
State of Hawaii
Benefit, Employment & Support Services Division
Department of Human Services
CHILD CARE LICENSING SELF-CERTIFICATION FORM
Date:
Name of Child Care Center:
Address:
Phone:
Please attach the center’s completed Child Care Center Staff and Volunteer Listing (DHS 954)
and Staff Sequence Form (DHS 957) which should contain the most current information.
I certify the following:
1)
All staff listed on the attached Child Care Center Staff and Volunteer Listing form
qualify for the positions that they hold. This complies with the applicable child care
licensing rules, for Group Child Care Centers and Group Child Care Homes (17-892.1-
17), for Infant and Toddler Child Care Centers (17-895-16), or for Before and After-
School Child Care Centers (17-896-16).
2)
The staff-child ratios and staff-employment sequence for this center is met and
maintained at all times and in compliance with the child care licensing rules (§17-892.1-
18, §17-895-17 & §17-895-18, or 17-896-17) that apply to this center.
3)
The employment history clearances have been completed for all staff listed on the
attached Child Care Center Staff and Volunteer Listing form.
Name:
Title:
Signature:
DHS 969 (2/01)