24 Hour Unit Appeal Form - Colorado Department Of Human Services
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1
2Rev. 7/2014
Emergency Appeal defined as: an
24 HOUR UNIT APPEAL FORM
immediate child(ren) specific
Please Type Form.
placement or situation which may
jeopardize or disrupt a placement; or
Date:
___________________
License #:__________________________
a safety risk to a child(ren). Appeal
will be heard as soon as possible.
County/Facility Name:__________________________________________________________
Mailing Address:_________________________________________City/Zip:________________________________
Your Name: _______________________________________Telephone No._________________________________
Email Address:________________________________________________________
Check Type of Facility( check one):
Day Treatment
SRTC
Homeless Youth Shelter
Specialized Group Facility
County/Foster/Adoption
Residential Child Care Facility
CPA/Foster/Adoption
FFH Name: ____________________________________________________ FFH License #:_______________
FFH Location Address: ______________________________________ City/State/Zip: ___________________
Licensed Capacity and Ages: ______________________________________________________________________________
Date of Original License: _________________________
Date of Last visit by this Department*: ____________________ (include a copy of the Report of Inspection (ROI))
NOTE:
This is a requirement.
All appeals must include a copy of the most recent Report of Inspection (ROI). In addition, if
you are appealing a ROI being too stringently applied, a copy of the ROI you are appealing must also be attached to the
appeal.
(Counties are excluded from this requirement.)
What is the date this hardship was created? ___________________________________________________________
*Note: Request for waiver must be submitted within 60 days of the date on which the rule allegedly was too stringently
applied or created the hardship. Appeal forms received after this timeframe will not be processed.
The Rule number(s) is
REQUIRED
and your appeal will not be valid without the required rule number. List the specific
Rule number(s) for this appeal: _________________________________________________________________________
Rules can be found at
Secretary of State
Briefly describe the issue(s). Add a page if additional space is needed:
Page 1 of 2
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