Adult Day Health Care Program Self-Assessment Survey

ADULT DAY HEALTH CARE PROGRAM SURVEY REPORT

The following survey is required to document compliance with certification requirements of Article 28 Adult Day Health Care Programs.

1. Facility and Program Details: *This question is required.

Department of Health Region
County
City
Facility Type
Facility Location
Facility Name
Primary Facility Identification
Program Name
Program Identification
Facility Address
Zipcode

2. Did the program name recently change? *This question is required.

3. New Adult Day Health Care Program Name: *This question is required.

3. Has the Adult Day Health Care Program reopened? *This question is required.

4. Is Adult Day Health Care Program permanently closed? *This question is required.

4. When do you plan to reopen? *This question is required.

4. Have you submitted the closure plan to the Department of Health? *This question is required.

4. Date reopened *This question is required. This question requires a valid date format of MM/DD/YYYY.

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