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* 1. Name of Facility:

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* 2. Email Address:

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* 3. Department Vendor Number (DVN)

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* 4. County

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* 5. Please indicate your license status:

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* 6. Total Capacity:

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* 7. Number of Subsidy Children:

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* 8. Will your program be open while schools are closed?

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* 9. Beginning Date of Closure

Date

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* 10. Ending Date of Closure (if known)

Date

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* 11. Was the decision to close required by local public health or was it voluntary?

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* 12. If voluntary, what prompted your decision (i.e. staff absences, low attendance, social distancing, etc.)?

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* 13. If open and serving six children or less would you be willing to accept additional children up to a total of 10 (including your children up to age 13) to care for temporarily up to 90 days?

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* 14. If you are closing, do you have teachers who would be willing to help provide child care at a different center, in a child's home or their home?

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* 15. If yes, please provide their names, email addresses, and phone numbers:

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