DCF Test Online Provider Business Information Form

Page 1

General Information






Decline Release of Name
4-C will release your program name and information to families seeking child care by mail and through on-line referrals unless you instruct us otherwise. If you are no longer providing child care, please notify your regulatory agency.
  
Please complete this form for statistical and referral purposes.
Contact Information
Address Information
You can not make changes to your location address.  If this has changed,  please contact your licensor/certifier.

















Edit section title
4-C uses a text message system to occasionally send text messages to providers about events, opportunities, and reminders.


Enter numbers only with no spaces or additional characters. Example: 6085551234

By indicating yes, you consent to receive occasional text messages through an automatic system.  You can choose to opt out at any time.  Message and data rates apply. 

Ages of Children Served
* Ages served need to follow your license/certificate.
Please contact your regulatory agency if you need to modify your ages served.
Language Languages spoken by you or your staff (check all that apply)

Special Needs Training or Experience
Employer Sponsored



Please list all companies your program works with.
Special Needs Enrollment
In the last 12 months, have you provided child care for families who have children with documented disabilities and/or special health care needs?  

Page 2

Day of Operation *Must fall within licensed regulatory hours*

* Days of week and hours of operation need to follow your license/certificate.

Please contact your regulatory agency if you need to modify your schedule.

Preschool Options


4K Options
Please complete this section if your program is a 4K site that receives funding from a public school to provide 4K.


Schedules (check as many of the following that apply)

Program (check as many of the following that apply)

Page 3

Provider Rates
0 - 11 months
Part Time Full Time
Hourly
Daily
Weekly
Monthly
1 Year
Part Time Full Time
Hourly
Daily
Weekly
Monthly
2 Years
Part Time Full Time
Hourly
Daily
Weekly
Monthly
3 Years
Part Time Full Time
Hourly
Daily
Weekly
Monthly
4 Years
Part Time Full Time
Hourly
Daily
Weekly
Monthly
5 Years
Part Time Full Time
Hourly
Daily
Weekly
Monthly
6+ Years
Part Time Full Time
Hourly
Daily
Weekly
Monthly
Before School 6+ Years
Part Time .
Hourly
Daily
Weekly
Monthly
After School 6+ Years
Part Time .
Hourly
Daily
Weekly
Monthly
DCF 201.039(3) A child care administrative agency may refuse to authorize payment for child care services by a child care provider licensed under s. 48.65, Stats., if the provider refuses to submit documentation of the provider's child care prices in response to an agency request.


Page 4


Please enter a date format of: xx/xx/xxxx
Check all fees that apply
Discounts/Scholarships


Family Providers Benefits

Enter number of paid vacation days you give yourself per year

Enter number of paid sick days you give yourself per year
Check this box if you and your family are covered by health insurance
Policies








Page 5

 
Enrollment
Please complete the following program enrollment chart with the number of children enrolled today.
Include your own children that are enrolled, if applicable.
Full Time Part Time
0-11 months
1 Year
2 Year
3 Year
4 Year
5 Year
6 - 8 Years
9+ Years
Capacity
Has your operating capacity been reduced due to staffing issues, closed classrooms or program preference? 

Example:  Your regulated capacity is 130.  You choose not to fill 30 slots due to staffing, closed classrooms, program preferences, etc.  Your operating capacity is 100. 

Child Care for Homeless Families
In the last 12 months, have you provided child care for families experiencing homelessness?    

Page 6

Vacancies
This information is provided to families seeking child care.

Vacancy information older than 60 days will not be displayed on referral printouts.
A vacancy only form will be emailed to you soon for ease in updating just your vacancies.
Total Vacancy Section

As of today, how many total vacancies do you have for each age group? 


Full time  is more than 20 hours/week.

Part Time is 20 hours or less/week.


The total of these four categories below should equal

the total number of vacancies in your programs.


Total Full Time Vacancies Total Part Time Vacancies
0-23 months
2+ years
This is an example of vacancy information provided to families.
refprint vacancy image
Part Time vacancies.  Check all boxes that apply.
Full Time vacancies.  Check all boxes that apply.

Open Vacancy Section
The following vacancy information will be used for reporting purposes only and will not be individually identifiable.

How many children in each age group could you enroll today?  


Full time  is more than 20 hours/week. 

Part Time is 20 hours or less/week.


Full Time Part Time
0-11 months
 1 Year
2 Years
3 Years
4 Years
5 Years
6+ Years
Waitlist
How many children are on your waitlist in each age group as of today?  
Waitlist
0-11 months
1 year
2 years
3 years
4 years
5 years
6+ years

Page 7

Expulsion Questions
In the last 12 months, how many children have been asked to leave your program for the following reasons.

The total from these 3 categories should equal the total number of children asked to leave your program.

Page 8

Group Programs
Group Centers/Preschools Policies






Enter the number of persons on staff who are:
.
Disability

Benefits (Check all benefits currently offered)


Enter number of paid vacation days staff members receive per year

Enter number of paid holidays staff receive per year

Enter number of paid holidays staff receive per year

Enter number of hours per week staff receive for prep/planning

Wage Information
Wage information is kept completely confidential and is used for statistical purposes only to generate important wages and benefits reports.

You can update your wage information by uploading a wage report that is broken out for each staff person.  Categories and options to report are listed below under Wage Information By Individual Staff Person


  
You can also complete the wage information on this form.
Select Yes to update staff wages on this form. (see below) Select No if you uploaded a form.
Wage Information By Individual Staff Person
Used only for your reference for future wage surveys
Hourly wages will never pre-fill on this form to protect confidential staff wages.
Indicate the highest level of schooling attained no matter what the area of study
Indicate the highest level of child care training attained
Statistical Questions
What is your race/ethnicity?  


Contact Information