DEPARTMENT OF CHILDREN AND FAMILIES Division of Early Care and Education YoungStar Rating Type Change Form Created August, 2012 This is a request to change the type of rating you receive in YoungStar. This request may be made up until 140 days prior to your YoungStar Anniversary Date (the anniversary of the date you were first rated in YoungStar). Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04(1)(m), Wisconsin Statutes]. If you are changing the type of rating you would like to receive, please indicate if you would like technical assistance. If you want technical assistance, please indicate if you want it before or after your rating. If you have a current star rating, your current star rating will remain in effect until the new type of rating completed. If you have questions on this form, call your local YoungStar office or the main YoungStar number: 1-888-713-KIDS Date Provider Number Today’s Name Program – Location Number Facility Number (if applicable) Name Director / Owner – Name Contact Person (if different from Director / Owner) – Address Child Care Program / Center (Street, City, Zip Code) County Child Care Program / Center – – Telephone Number Cell Phone Number Email Address Program requests a new rating, dated as above, because I want to change the type of rating I receive. Please choose the type of rating you would like below and choose if you would like your technical assistance before or after being rated. Note: Technical assistance is not available before Automated Rating. Type of rating I would like to receive (choose one): Automated Technical Formal Rating I would like to receive my technical assistance (choose one): Before rating After rating SIGNATURE Person Making Request: ____________________________________ Date Signed: _______________ – (effective date) For Local YoungStar Office Use Only Date Received Initials Date Processed Initials
DEPARTMENT OF CHILDREN AND FAMILIES Division of Early Care and Education YoungStar Rating Type Change Form Created August, 2012 This is a request to change the type of rating you receive in YoungStar. This request may be made up until 140 days prior to your YoungStar Anniversary Date (the anniversary of the date you were first rated in YoungStar). Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04(1)(m), Wisconsin Statutes]. If you are changing the type of rating you would like to receive, please indicate if you would like technical assistance. If you want technical assistance, please indicate if you want it before or after your rating. If you have a current star rating, your current star rating will remain in effect until the new type of rating completed. If you have questions on this form, call your local YoungStar office or the main YoungStar number: 1-888-713-KIDS Today’s Date Provider Number Name – Program Location Number Facility Number (if applicable) Name – Director / Owner Name – Contact Person (if different from Director / Owner) Address – Child Care Program / Center (Street, City, Zip Code) County – Child Care Program / Center Telephone Number Cell Phone Number Email Address Program requests a new rating, dated as above, because I want to change the type of rating I receive. Please choose the type of rating you would like below and choose if you would like your technical assistance before or after being rated. Note: Technical assistance is not available before Automated Rating. Type of rating I would like to receive (choose one): Automated Technical Formal Rating I would like to receive my technical assistance (choose one): Before rating After rating SIGNATURE – Person Making Request: ____________________________________ Date Signed: _______________ (effective date) For Local YoungStar Office Use Only Date Received Initials Date Processed Initials
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