Local Planning Council Forms-z2

Agency Annual Report

1. Legal Name of Agency.
2. Vendor Number.
3. Agency Contact Name.
4. Agency Contact Phone Number.
5. Date Agency Self Evaluation Completed.
6. Date of Current Needs Assessment.
7. Date of Current Comprehensive Child Care and Development Plan.
8. Program Year.
9. Annual Report Process Description: Describe the annual report process and who participated in the process. Describe the role and level of participation and contribution by parents, staff, Board of Supervisors, Superintendent of Schools and your Local Planning Council (LPC) members in the self evaluation process. Include the start and completion date of your self evaluation and annual report process. Include information regarding the update of the LPC Program Coordinator and LPC member handbooks to reflect the new requirements and documentation of the new self evaluation process.
10. By checking this box, I certify that an agency Self Evaluation has been completed by this agency on the date specified above and that the appropriate review instrument(s) were used. Authorized Agency Representative: check upon completion.
11. Name of Authorized Agency Representative.
12. Date of Authorized Agency Representative Certification.
13. By checking this box, I certify that at least one LPC Representative who participated in the agency's completed self evaluation process (described above) has reviewed and approved this document. LPC Representative: check upon completion.
14. Name of LPC Chairperson or Representative.
15. Date of LPC Chairperson or Representative Certification.