FCCERS-R Assessment Request Form

FCCERS-R Assessment Request

Step 1 of 3

Directions: Please complete this form to request that a valid and reliable observation tool that will measure overall quality of the program, be conducted. The cost of this observation is $500, which includes a minimum of three hours of observation 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?*

Family Child Care Rating Scale (FCCERS-R)
Cost for FCCERS-R $500.00
Please enter the number of children that will be present during observation? Cannot be less than 2 present to conduct the assessment.*
How will you use the FCCERS-R results in your program?*
Please give three (3) dates you would like to hold for the observation.

Name*
First Last
Email*

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

Hours of Operation Start Time*

: Hours

Minutes

AM/PM

Hours of Operation End Time*

: Hours

Minutes

AM/PM

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 $500, which includes a minimum of three hours of observation and a written report, completed within 3 business days of the visit.