Facility Name: Facility Number: Facility Address: Type of requested capacity change: Increase Decrease Licensed capacity: Current census Requested capacity Justification for the change in capacity: If seeking a capacity increase, describe how the facility will accommodate the change (If applicable, include any changes in operational and/or dispensing hours and parking): STAFFING: Current # of FTE counseling staff : Proposed # of FTE counseling staff : Current # of FTE dispensing staff : Proposed # of FTE dispensing staff : ** Attach a copy outlining the name and discipline for each medical staff, proposed hours worked weekly upon approval of request. NOTE: A recent floor plan must be attached to the request. If renovation and/or expansion require a revised Certificate of Occupancy, it must be submitted with request. Signature of Facility or Project Director Date ******************************FOR DDAP USE ONLY******************************** APPROVED DENIED (see attached letter) Date: REASON:
Facility Name: Facility Number: Facility Address: Type of requested capacity change: Increase Decrease Licensed capacity: Current census Requested capacity Justification for the change in capacity: If seeking a capacity increase, describe how the facility will accommodate the change (If applicable, include any changes in operational and/or dispensing hours and parking): STAFFING: Current # of FTE counseling staff : Proposed # of FTE counseling staff : Current # of FTE dispensing staff : Proposed # of FTE dispensing staff : ** Attach a copy outlining the name and discipline for each medical staff, proposed hours worked weekly upon approval of request. NOTE: A recent floor plan must be attached to the request. If renovation and/or expansion require a revised Certificate of Occupancy, it must be submitted with request. Signature of Facility or Project Director Date ******************************FOR DDAP USE ONLY******************************** APPROVED DENIED (see attached letter) Date: REASON: