DEPARTMENT OF HEALTH SERVICES
Division of Quality Assurance F-60367 (Rev. 04/09)
STATE OF WISCONSIN
Chapter 50.03, Wis. Stats.
COMMUNITY ADVISORY COMMITTEE DOCUMENTATION
The information collected on this form may be used to document good faith effort by the licensee to establish a community advisory committee as required in Chapter 50.03, Wis. Stats., and DHS 83.05(3), Wis. Admin. Code. Completion of this form is optional and other forms of documentation may be accepted. The license applicant will complete and maintain this form, or other forms of documentation, such as meeting minutes, agenda items, and attendees, in the facility's files for review by the licensing specialist.
Name - Proposed Facility Address City State Zip Code
1. If you had a meeting with area neighbors, please respond to the following questions: a. On what date was your meeting with area neighbors held? b. How many people attended this meeting? 2. If you do not plan to hold a meeting with area neighbors, please explain below how you made a good faith effort to establish a community advisory committee. Verifiable documentation of your effort to communicate with area neighbors must be maintained in facility files.
3. Is a community advisory committee being formed?
Yes
No
a. If "Yes," please provide the information pertinent to the composition of your committee on the back of this form. b. If "No," please explain on the back of this form why a committee is not being formed.
SIGNATURE Applicant Date Signed
Address
City
State
Zip Code