DRAFT - Environmental Health Inspection (In-Home Daycare)

Environmental Health Inspection (In-Home Daycare)
For more information, please refer to Utah Rule:
Date*

MonthDayYear
Date
Type of Inspection/Facility*
Facility Name:*
Facility Address (physical and mailing)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Owner's Name

First NameLast Name
Owner's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Owner's Phone Number
Please enter a valid phone number.
Owner's Email
example@example.com

Contact Name

First NameLast Name
Contact Phone Number
Please enter a valid phone number.
Contact Email
example@example.com

Does this report need to be sent to another agency?
Facility Name
Facility Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Facility Email
example@example.com

IF THIS IS A NEW FACILITY, YOU WILL NEED TO SUBMIT A SCHOOL REVIEW APPLICATION PRIOR TO BEING CONSIDERED FOR AN OPERATIONAL PERMIT.

Fee*

Plan Review Fee

$100.00 Quantity

Total

$0.00

Credit Card

Should be Empty: