Alternative Compliance Request
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1Division of Public Health - Licensure Unit - Children’s Services Licensing Program
Department of Health & Human Services
Alternative Compliance Request
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Check the appropriate box for the type of license for which you are requesting an Alternative Compliance:
FAMILY CHILD CARE HOME I
FAMILY CHILD CARE HOME II
PRESCHOOL
CHILD CARE CENTER
SCHOOL-AGE ONLY CENTER
Retain PINK copy for your records. Submit WHITE & YELLOW copies to your Child Care Inspection Specialist.
SECTION I: TO BE COMPLETED BY LICENSEE/PROVIDER
Name of Licensee/Provider
Facility Name (if applicable)
Street Address
City
State
Zip Code
Regulation used for request (indicate Page # and Nebraska Administrative Code reference):
Reason for request:
How will compliance be met with the intent of the regulation?
How will the Alternative Compliance offer the same protection as the regulation?
Signature of Licensee/Provider
Date Signed
SECTION II: TO BE COMPLETED BY CHILD CARE INSPECTION SPECIALIST
Recommendation:
Approve
Deny
Reason:
Authorized Signature
Date Signed
SECTION III: TO BE COMPLETED BY CHILD CARE LICENSING SUPERVISOR
The Department of Health and Human Services, Division of Public Health, hereby denies alternative compliance with
the above regulation.
The Department of Health and Human Services, Division of Public Health, hereby grants alternative compliance with
the above regulation and is effective from
to
.
Authorized Signature
Date Signed
Distribution: WHITE - Central Office; YELLOW - Child Care Inspection Specialist/Staff
CRED-914 Rev. 4/13 (57015)
Assistant; PINK - Licensee/Provider
(DO NOT use previous version 05/99)
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