OREGON’S QUALITY RATING & IMPROVEMENT SYSTEM Program Application Program Name:
Date: ____________________
License #: Director/Provider/Owner Name:
Phone: (
Cell Work Home
)
Is this person the main contact/lead for the (QRIS/Spark)?: YES NO If no, who?: Name:
Title:
Email Address (of lead person): Program Mailing Address:
Cell
Phone: (
) ____________________ Work
Home
_________________________________________________________________________ Street Address City
Program Physical Address: Check if same as mailing
State
Zip
_________________________________________________________________________ Street Address City
State
Zip
County (of physical address): A Spark rating is associated with a licensed site and a separate application must be completed for each site. Will applications be completed for more than one site? YES NO. If yes, this is #______ of #______ (e.g., 1 of 4). Multi-Site programs may qualify to use a streamlined portfolio for individual sites. For more information, contact the Helpline: 877-768-8290 or
[email protected]. The Multi-Site Registration Form will be needed. Age Groups Served
Number Enrolled
6 weeks – 17 months
Age Groups Served
Number Enrolled
4 year olds
18 months – 35 months
5 year olds
3 year olds
6 – 12 year olds
Total number of staff (that work with children and are counted in ratio): Hours of operation: Number of children served that are receiving special education services (on an IFSP or IEP): Are there multiple classrooms? NO YES If yes, how many: Name of Classroom
Rev. 1/2018
Ages Served
and please complete information below: Name of Classroom
Ages Served
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GENERAL PROGRAM INFORMATION A.
Is this program currently accredited? YES NO If yes, by which accrediting agency? NAEYC NAFCC ASCI AMS Other
B.
Is this program participating in a focused network/cohort? YES NO If yes, which one? (name or location)
C. Is this program participating in Preschool Promise? YES NO D.
Is the Director/Provider also the owner of the program? YES NO
E.
Is this program enrolled and participating in the USDA CACFP (United States Department of Agriculture Child and Adult Care Food Program)? YES NO
REQUIREMENTS FOR PARTICIPATION In order to participate in Spark, a program lead must answer the questions below and the program must meet the listed compliance requirements. Compliance will be verified with the Office of Child Care. 1. Has the director/provider or QRIS lead received an orientation? Yes Date: No
Where?:
By?:
2. Is this program currently licensed by the Office of Child Care/Early Learning Division? Yes Total number of years/months licensed: No
Explain: ___________________________________________________
3. How long has this program been in operation?
(years/months) Estimate if not sure.
4. Does this program currently have liability insurance? Yes No 5. Does this program currently serve families receiving state subsidies (such as Employment Related Day Care)? Yes No 6. Does this program meet the compliance history requirements for a Commitment to Quality designation listed below? Yes No If no, please explain: Compliance history requirements to receive and maintain a Commitment to Quality designation: • •
No more than 2 valid findings of serious violations* in the past 24 months, AND No civil penalties in the past 12 months *Serious Violations: 1. Children are in imminent danger 2. More children in care than allowed by law 3. Corporal punishment or other specific forms of inappropriate discipline are being used 4. Children not being supervised 5. Multiple or serious fire, health, or safety hazards 6. Extreme unsanitary conditions 7. Adults are present who are not enrolled in the Office of Child Care’s Central Background Registry 8. Providing care without being licensed with the Office of Child Care as required by rule
Rev. 1/2018
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The compliance history below is for informational purposes only. Compliance history requirements to receive and maintain a star rating For a 3-Star Rating, a program must not have: • •
Any valid findings of serious violations* in the past 12 months, AND Civil penalties in the past 12 months
For a 4- or 5-Star Rating, a program must not have: • •
Any valid findings of serious violations* in the past 24 months, AND Civil penalties in the past 24 months
NEXT STEPS Return this application with: 1. Self-Assessment 2. Signed Memorandum of Understanding The Research Institute at Western Oregon University (TRI) will review the application and verify responses. If the program meets the requirements and includes copies of a completed Self-Assessment and signed Memorandum of Understanding, they will receive the Commitment to Quality designation. This will enable the program to proceed further in the QRIS process to work towards a 3-, 4-, or 5- star designation. TRI will send the program a Welcome Kit which will contain a certificate, a portfolio and other materials needed to participate. If it is determined the program does not meet participation requirements, you will be contacted with the reason(s) why. Programs may reapply. I verify that the information submitted is accurate.
_____________________________________________________________________ (Print Full Name)
____________________________________________________ (Title)
_____________________________________________________________________ (Signature)
___________________________________________________ (Date)
Send application materials to: Spark, Oregon’s QRIS The Research Institute Western Oregon University 345 N. Monmouth Ave Monmouth, OR 97361 Toll Free QRIS Helpline: 877-768-8290
Rev. 1/2018
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