BAS Assessment Request Form

BAS Assessment Request

Step 1 of 3

Directions: Please complete this form to request that a valid and reliable assessment tool that will measure overall quality of the program. The cost of this assessment is $300, which includes an interview and a written report, completed within 3 business days of the visit. Please complete this form in its entirety.
What environmental rating scale do you need?*

Business Administrative Scale
Cost for BAS $300.00
How will you use the BAS results in your program?*
Please give three (3) dates you would like to hold for the assessment.

Name*
First Last
Email*

Phone*
Address*
Street Address Address Line 2 City ZIP Code

Hours of Operation Start Time*

: Hours

Minutes

Hours of Operation End Time*

: Hours

Minutes

I agree to terms and service*

I acknowledge payment will be paid directly to the United Way of Connecticut. The cost of this observation is $300, which includes a 1-hour interview, review of documents and a written report, completed within 3 business days of the visit.