CHILD CARE REQUEST & NOTIFICATION FORM

(To be completed by Family Services Specialist prior to a child receiving child care services or transferring to another child care provider. To be submitted electronically to the CSA Coordinator. Approved request to be forwarded to the requesting Family Services Specialist and the Support Team.)

Date:	Worker:	Supervisor:

Child’s Name:	DOB:	Age:

OASIS Case Number:

CSA Interim or FAPT approval is required for all child care arrangements. Ongoing FAPT approval is needed to fund child care expenses.

Child care is being requested to provide daily supervision during the foster parent(s) working hours when the child is not in school. The Family Services Specialist must document in OASIS that the foster parent(s) meets the requirement for child care expenses and attach a copy of this documentation to this form which will be maintained in the child’s eligibility record.

Child care is being requested to continue to provide daily supervision while the child is on a trial home visit during the parent/relative(s) working hours when the child is not in school.

(Note: If this is a two parent home, both parents should be employed to receive child care services.)

Child Care is requested to begin on	.

Child Care Provider:

Street Address:

City:	State:	Zip:

Telephone #:

Per policy, a diligent effort should be made to secure fully approved child care for foster children at costs no greater than the established maximum reimbursable rates. These rates are established in accordance with federal regulatory requirements.

Maximum Reimbursement Rate $	Agreed upon Rate $	Annual Registration Fee $

(As established from worksheet from page 2-8)

If the agreed upon rate is higher than the maximum reimbursement rate than the Justification Worksheet on page three MUST be completed.

IF the child is/was previously in another child care placement, Child Care ended at and the last date of attendance was or is scheduled for .

Approved: Yes No

CSA Coordinator Signature	Date

VIRGINIA BEACH Child Care Maximum Reimbursement Rates Worksheet

MMR rates are locality specific. Child Care providers shall receive the MRR specific to the locality in which the provider is located. , i.e. if a foster child resides in Virginia Beach and receives Child Care services through a provider in Chesapeake, the provider’s rate will be based on the MRR for Chesapeake.

Answer the following questions about the provider and child in order to determine the maximum reimbursement rate. (Note: The provider MUST be licensed.):

Check One:	Level 1 Provider	Level 2 Provider

Unregulated vendors including in-home vendors (in-home vendors are paid minimum wage not to exceed Level 1 MRR for # of children in care)
Voluntarily Registered Family Day Homes
Religiously-Exempt Day Centers
Local Government-Approved Recreation Programs
Certified Preschools
Licensed Family Day Homes
Licensed Child Day Centers (including Short-Term Child Day Centers)
Licensed Family Day System-Approved Family Day Homes
Department of Education-Approved Child Care Programs
Child Care Centers run by the United States Department of Defense

Check One:	Check One:

Family Day Home	Child Day Center	Family Day Home	Child Day Center

Check One:	Check One:	Check One:	Check One:
Infant – Birth to 16 mths	Infant – Birth to 16 mths	Infant – Birth to 16 mths	Infant – Birth to 16 mths
Weekly $95.00	Weekly $140.00	Weekly $150.00	Weekly $205.00
Full Day (Part-Time Only)	Full Day (Part-Time Only)	Full Day (Part-Time Only)	Full Day (Part-Time Only)
$19.00	$28.00	$30.00	$41.00
Toddler – 16 mths to 24 mths	Toddler – 16 mths to 24 mths	Toddler – 16 mths to 24 mths	Toddler – 16 mths to 24 mths
Weekly $85.00	Weekly $130.00	Weekly $135.00	Weekly $180.00
Full Day (Part-Time Only)	Full Day (Part-Time Only)	Full Day (Part-Time Only)	Full Day (Part-Time Only)
$17.00	$26.00	$27.00	$36.00
Preschool – 24 mths to 5 yrs	Preschool – 24 mths to 5 yrs	Preschool – 24 mths to 5 yrs	Preschool – 24 mths to 5 yrs
Weekly $80.00	Weekly $105.00	Weekly $135.00	Weekly $160.00
Full Day (Part-Time Only)	Full Day (Part-Time Only)	Full Day (Part-Time Only)	Full Day (Part-Time Only)
$16.00	$21.00	$27.00	$32.00
School Age – 5+ (attending)	School Age – 5+ (attending)	School Age – 5+ (attending)	School Age – 5+ (attending)
Weekly $75.00	Weekly $100.00	Weekly $125.00	Weekly $150.00
Full Day (Part-Time Only)	Full Day (Part-Time Only)	Full Day (Part-Time Only)	Full Day (Part-Time Only)
$15.00	$20.00	$25.00	$30.00
Before/After Only Weekly	Before/After Only Weekly	Before/After Only Weekly	Before/After Only Weekly
Weekly $55.00	Weekly $70.00	Weekly $90.00	Weekly $105.00

A provider search can be conducted at http://www.dss.virginia.gov/facility/search/cc.cgi to determine the facility type (Level 1 or Level 2).

"Family day home" means a child day program offered in the residence of the vendor or the home of any of the children in care for one through 12 children under the age of 13, exclusive of the vendor’s own children and any children who reside in the home, when at least one child receives care for compensation.

"Child day center" means a child day program offered to two or more children under the age of 13 in a facility that is not the residence of the vendor or of any of the children in care or 13 or more children at any location.

CHESAPEAKE Child Care Maximum Reimbursement Rates Worksheet

MMR rates are locality specific. Child Care providers shall receive the MRR specific to the locality in which the provider is located. , i.e. if a foster child resides in Virginia Beach and receives Child Care services through a provider in Chesapeake, the provider’s rate will be based on the MRR for Chesapeake.

Answer the following questions about the provider and child in order to determine the maximum reimbursement rate. (Note: The provider MUST be licensed.):

Check One:	Level 1 Provider	Level 2 Provider

Unregulated vendors including in-home vendors (in-home vendors are paid minimum wage not to exceed Level 1 MRR for # of children in care)
Voluntarily Registered Family Day Homes
Religiously-Exempt Day Centers
Local Government-Approved Recreation Programs
Certified Preschools
Licensed Family Day Homes
Licensed Child Day Centers (including Short-Term Child Day Centers)
Licensed Family Day System-Approved Family Day Homes
Department of Education-Approved Child Care Programs
Child Care Centers run by the United States Department of Defense

Check One:	Check One:

Family Day Home	Child Day Center	Family Day Home	Child Day Center

Check One:	Check One:	Check One:	Check One:
Infant – Birth to 16 mths	Infant – Birth to 16 mths	Infant – Birth to 16 mths	Infant – Birth to 16 mths
Weekly $90.00	Weekly $135.00	Weekly $130.00	Weekly $195.00
Full Day (Part-Time Only)	Full Day (Part-Time Only)	Full Day (Part-Time Only)	Full Day (Part-Time Only)
$18.00	$27.00	$26.00	$39.00
Toddler – 16 mths to 24 mths	Toddler – 16 mths to 24 mths	Toddler – 16 mths to 24 mths	Toddler – 16 mths to 24 mths
Weekly $85.00	Weekly $125.00	Weekly $125.00	Weekly $175.00
Full Day (Part-Time Only)	Full Day (Part-Time Only)	Full Day (Part-Time Only)	Full Day (Part-Time Only)
$17.00	$25.00	$25.00	$35.00
Preschool – 24 mths to 5 yrs	Preschool – 24 mths to 5 yrs	Preschool – 24 mths to 5 yrs	Preschool – 24 mths to 5 yrs
Weekly $85.00	Weekly $100.00	Weekly $110.00	Weekly $150.00
Full Day (Part-Time Only)	Full Day (Part-Time Only)	Full Day (Part-Time Only)	Full Day (Part-Time Only)
$17.00	$20.00	$22.00	$30.00
School Age – 5+ (attending)	School Age – 5+ (attending)	School Age – 5+ (attending)	School Age – 5+ (attending)
Weekly $75.00	Weekly $90.00	Weekly $100.00	Weekly $125.00
Full Day (Part-Time Only)	Full Day (Part-Time Only)	Full Day (Part-Time Only)	Full Day (Part-Time Only)
$15.00	$18.00	$20.00	$25.00
Before/After Only Weekly	Before/After Only Weekly	Before/After Only Weekly	Before/After Only Weekly
Weekly $55.00	Weekly $65.00	Weekly $80.00	Weekly $95.00

A provider search can be conducted at http://www.dss.virginia.gov/facility/search/cc.cgi to determine the facility type (Level 1 or Level 2).

"Family day home" means a child day program offered in the residence of the vendor or the home of any of the children in care for one through 12 children under the age of 13, exclusive of the vendor’s own children and any children who reside in the home, when at least one child receives care for compensation.

"Child day center" means a child day program offered to two or more children under the age of 13 in a facility that is not the residence of the vendor or of any of the children in care or 13 or more children at any location.

HAMPTON Child Care Maximum Reimbursement Rates Worksheet

MMR rates are locality specific. Child Care providers shall receive the MRR specific to the locality in which the provider is located. , i.e. if a foster child resides in Virginia Beach and receives Child Care services through a provider in Chesapeake, the provider’s rate will be based on the MRR for Chesapeake.

Answer the following questions about the provider and child in order to determine the maximum reimbursement rate. (Note: The provider MUST be licensed.):

Check One:	Level 1 Provider	Level 2 Provider

Unregulated vendors including in-home vendors (in-home vendors are paid minimum wage not to exceed Level 1 MRR for # of children in care)
Voluntarily Registered Family Day Homes
Religiously-Exempt Day Centers
Local Government-Approved Recreation Programs
Certified Preschools
Licensed Family Day Homes
Licensed Child Day Centers (including Short-Term Child Day Centers)
Licensed Family Day System-Approved Family Day Homes
Department of Education-Approved Child Care Programs
Child Care Centers run by the United States Department of Defense

Check One:	Check One:

Family Day Home	Child Day Center	Family Day Home	Child Day Center

Check One:	Check One:	Check One:	Check One:
Infant – Birth to 16 mths	Infant – Birth to 16 mths	Infant – Birth to 16 mths	Infant – Birth to 16 mths
Weekly $85.00	Weekly $125.00	Weekly $130.00	Weekly $175.00
Full Day (Part-Time Only)	Full Day (Part-Time Only)	Full Day (Part-Time Only)	Full Day (Part-Time Only)
$17.00	$25.00	$26.00	$35.00
Toddler – 16 mths to 24 mths	Toddler – 16 mths to 24 mths	Toddler – 16 mths to 24 mths	Toddler – 16 mths to 24 mths
Weekly $85.00	Weekly $105.00	Weekly $120.00	Weekly $160.00
Full Day (Part-Time Only)	Full Day (Part-Time Only)	Full Day (Part-Time Only)	Full Day (Part-Time Only)
$17.00	$21.00	$24.00	$35.00
Preschool – 24 mths to 5 yrs	Preschool – 24 mths to 5 yrs	Preschool – 24 mths to 5 yrs	Preschool – 24 mths to 5 yrs
Weekly $75.00	Weekly $90.00	Weekly $110.00	Weekly $130.00
Full Day (Part-Time Only)	Full Day (Part-Time Only)	Full Day (Part-Time Only)	Full Day (Part-Time Only)
$15.00	$18.00	$22.00	$26.00
School Age – 5+ (attending)	School Age – 5+ (attending)	School Age – 5+ (attending)	School Age – 5+ (attending)
Weekly $75.00	Weekly $80.00	Weekly $100.00	Weekly $120.00
Full Day (Part-Time Only)	Full Day (Part-Time Only)	Full Day (Part-Time Only)	Full Day (Part-Time Only)
$15.00	$18.00	$20.00	$24.00
Before/After Only Weekly	Before/After Only Weekly	Before/After Only Weekly	Before/After Only Weekly
Weekly $55.00	Weekly $55.00	Weekly $80.00	Weekly $85.00

A provider search can be conducted at http://www.dss.virginia.gov/facility/search/cc.cgi to determine the facility type (Level 1 or Level 2).

"Family day home" means a child day program offered in the residence of the vendor or the home of any of the children in care for one through 12 children under the age of 13, exclusive of the vendor’s own children and any children who reside in the home, when at least one child receives care for compensation.

"Child day center" means a child day program offered to two or more children under the age of 13 in a facility that is not the residence of the vendor or of any of the children in care or 13 or more children at any location.

NEWPORT NEWS Child Care Maximum Reimbursement Rates Worksheet

MMR rates are locality specific. Child Care providers shall receive the MRR specific to the locality in which the provider is located. , i.e. if a foster child resides in Virginia Beach and receives Child Care services through a provider in Chesapeake, the provider’s rate will be based on the MRR for Chesapeake.

Answer the following questions about the provider and child in order to determine the maximum reimbursement rate. (Note: The provider MUST be licensed.):

Check One:	Level 1 Provider	Level 2 Provider

Unregulated vendors including in-home vendors (in-home vendors are paid minimum wage not to exceed Level 1 MRR for # of children in care)
Voluntarily Registered Family Day Homes
Religiously-Exempt Day Centers
Local Government-Approved Recreation Programs
Certified Preschools
Licensed Family Day Homes
Licensed Child Day Centers (including Short-Term Child Day Centers)
Licensed Family Day System-Approved Family Day Homes
Department of Education-Approved Child Care Programs
Child Care Centers run by the United States Department of Defense

Check One:	Check One:

Family Day Home	Child Day Center	Family Day Home	Child Day Center

Check One:	Check One:	Check One:	Check One:
Infant – Birth to 16 mths	Infant – Birth to 16 mths	Infant – Birth to 16 mths	Infant – Birth to 16 mths
Weekly $85.00	Weekly $120.00	Weekly $130.00	Weekly $175.00
Full Day (Part-Time Only)	Full Day (Part-Time Only)	Full Day (Part-Time Only)	Full Day (Part-Time Only)
$17.00	$24.00	$26.00	$35.00
Toddler – 16 mths to 24 mths	Toddler – 16 mths to 24 mths	Toddler – 16 mths to 24 mths	Toddler – 16 mths to 24 mths
Weekly $80.00	Weekly $120.00	Weekly $120.00	Weekly $145.00
Full Day (Part-Time Only)	Full Day (Part-Time Only)	Full Day (Part-Time Only)	Full Day (Part-Time Only)
$16.00	$24.00	$24.00	$29.00
Preschool – 24 mths to 5 yrs	Preschool – 24 mths to 5 yrs	Preschool – 24 mths to 5 yrs	Preschool – 24 mths to 5 yrs
Weekly $70.00	Weekly $100.00	Weekly $110.00	Weekly $125.00
Full Day (Part-Time Only)	Full Day (Part-Time Only)	Full Day (Part-Time Only)	Full Day (Part-Time Only)
$14.00	$20.00	$22.00	$25.00
School Ag e– 5+ (attending)	School Age – 5+ (attending)	School Age – 5+ (attending)	School Age – 5+ (attending)
Weekly $75.00	Weekly $85.00	Weekly $105.00	Weekly $115.00
Full Day (Part-Time Only)	Full Day (Part-Time Only)	Full Day (Part-Time Only)	Full Day (Part-Time Only)
$15.00	$17.00	$21.00	$23.00
Before/After Only Weekly	Before/After Only Weekly	Before/After Only Weekly	Before/After Only Weekly
Weekly $55.00	Weekly $60.00	Weekly $70.00	Weekly $85.00

A provider search can be conducted at http://www.dss.virginia.gov/facility/search/cc.cgi to determine the facility type (Level 1 or Level 2).

"Family day home" means a child day program offered in the residence of the vendor or the home of any of the children in care for one through 12 children under the age of 13, exclusive of the vendor’s own children and any children who reside in the home, when at least one child receives care for compensation.

"Child day center" means a child day program offered to two or more children under the age of 13 in a facility that is not the residence of the vendor or of any of the children in care or 13 or more children at any location.

NORFOLK Child Care Maximum Reimbursement Rates Worksheet

MMR rates are locality specific. Child Care providers shall receive the MRR specific to the locality in which the provider is located. , i.e. if a foster child resides in Virginia Beach and receives Child Care services through a provider in Chesapeake, the provider’s rate will be based on the MRR for Chesapeake.

Answer the following questions about the provider and child in order to determine the maximum reimbursement rate. (Note: The provider MUST be licensed.):

Check One:	Level 1 Provider	Level 2 Provider

Unregulated vendors including in-home vendors (in-home vendors are paid minimum wage not to exceed Level 1 MRR for # of children in care)
Voluntarily Registered Family Day Homes
Religiously-Exempt Day Centers
Local Government-Approved Recreation Programs
Certified Preschools
Licensed Family Day Homes
Licensed Child Day Centers (including Short-Term Child Day Centers)
Licensed Family Day System-Approved Family Day Homes
Department of Education-Approved Child Care Programs
Child Care Centers run by the United States Department of Defense

Check One:	Check One:

Family Day Home	Child Day Center	Family Day Home	Child Day Center

Check One:	Check One:	Check One:	Check One:
Infant – Birth to 16 mths	Infant – Birth to 16 mths	Infant – Birth to 16 mths	Infant – Birth to 16 mths
Weekly $90.00	Weekly $125.00	Weekly $125.00	Weekly $175.00
Full Day (Part-Time Only)	Full Day (Part-Time Only)	Full Day (Part-Time Only)	Full Day (Part-Time Only)
$18.00	$25.00	$25.00	$35.00
Toddler – 16 mths to 24 mths	Toddler – 16 mths to 24 mths	Toddler – 16 mths to 24 mths	Toddler – 16 mths to 24 mths
Weekly $80.00	Weekly $120.00	Weekly $110.00	Weekly $155.00
Full Day (Part-Time Only)	Full Day (Part-Time Only)	Full Day (Part-Time Only)	Full Day (Part-Time Only)
$16.00	$24.00	$22.00	$31.00
Preschool – 24 mths to 5 yrs	Preschool – 24 mths to 5 yrs	Preschool – 24 mths to 5 yrs	Preschool – 24 mths to 5 yrs
Weekly $75.00	Weekly $100.00	Weekly $100.00	Weekly $135.00
Full Day (Part-Time Only)	Full Day (Part-Time Only)	Full Day (Part-Time Only)	Full Day (Part-Time Only)
$15.00	$20.00	$20.00	$27.00
School Age – 5+ (attending)	School Age – 5+ (attending)	School Age – 5+ (attending)	School Age – 5+ (attending)
Weekly $70.00	Weekly $90.00	Weekly $90.00	Weekly $110.00
Full Day (Part-Time Only)	Full Day (Part-Time Only)	Full Day (Part-Time Only)	Full Day (Part-Time Only)
$14.00	$18.00	$18.00	$22.00
Before/After Only Weekly	Before/After Only Weekly	Before/After Only Weekly	Before/After Only Weekly
Weekly $50.00	Weekly $65.00	Weekly $70.00	Weekly $75.00

A provider search can be conducted at http://www.dss.virginia.gov/facility/search/cc.cgi to determine the facility type (Level 1 or Level 2).

"Family day home" means a child day program offered in the residence of the vendor or the home of any of the children in care for one through 12 children under the age of 13, exclusive of the vendor’s own children and any children who reside in the home, when at least one child receives care for compensation.

"Child day center" means a child day program offered to two or more children under the age of 13 in a facility that is not the residence of the vendor or of any of the children in care or 13 or more children at any location.

PORTSMOUTH Child Care Maximum Reimbursement Rates Worksheet

MMR rates are locality specific. Child Care providers shall receive the MRR specific to the locality in which the provider is located. , i.e. if a foster child resides in Virginia Beach and receives Child Care services through a provider in Chesapeake, the provider’s rate will be based on the MRR for Chesapeake.

Answer the following questions about the provider and child in order to determine the maximum reimbursement rate. (Note: The provider MUST be licensed.):

Check One:	Level 1 Provider	Level 2 Provider

Unregulated vendors including in-home vendors (in-home vendors are paid minimum wage not to exceed Level 1 MRR for # of children in care)
Voluntarily Registered Family Day Homes
Religiously-Exempt Day Centers
Local Government-Approved Recreation Programs
Certified Preschools
Licensed Family Day Homes
Licensed Child Day Centers (including Short-Term Child Day Centers)
Licensed Family Day System-Approved Family Day Homes
Department of Education-Approved Child Care Programs
Child Care Centers run by the United States Department of Defense

Check One:	Check One:

Family Day Home	Child Day Center	Family Day Home	Child Day Center

Check One:	Check One:	Check One:	Check One:
Infant – Birth to 16 mths	Infant – Birth to 16 mths	Infant – Birth to 16 mths	Infant – Birth to 16 mths
Weekly $75.00	Weekly $130.00	Weekly $125.00	Weekly $200.00
Full Day (Part-Time Only)	Full Day (Part-Time Only)	Full Day (Part-Time Only)	Full Day (Part-Time Only)
$15.00	$26.00	$25.00	$40.00
Toddler – 16 mths to 24 mths	Toddler – 16 mths to 24 mths	Toddler – 16 mths to 24 mths	Toddler – 16 mths to 24 mths
Weekly $75.00	Weekly $95.00	Weekly $100.00	Weekly $175.00
Full Day (Part-Time Only)	Full Day (Part-Time Only)	Full Day (Part-Time Only)	Full Day (Part-Time Only)
$15.00	$19.00	$20.00	$34.00
Preschool – 24 mths to 5 yrs	Preschool – 24 mths to 5 yrs	Preschool – 24 mths to 5 yrs	Preschool – 24 mths to 5 yrs
Weekly $70.00	Weekly $85.00	Weekly $95.00	Weekly $140.00
Full Day (Part-Time Only)	Full Day (Part-Time Only)	Full Day (Part-Time Only)	Full Day (Part-Time Only)
$14.00	$17.00	$19.00	$28.00
School Age – 5+ (attending)	School Age – 5+ (attending)	School Age – 5+ (attending)	School Age – 5+ (attending)
Weekly $65.00	Weekly $85.00	Weekly $90.00	Weekly $120.00
Full Day (Part-Time Only)	Full Day (Part-Time Only)	Full Day (Part-Time Only)	Full Day (Part-Time Only)
$13.00	$17.00	$18.00	$24.00
Before/After Only Weekly	Before/After Only Weekly	Before/After Only Weekly	Before/After Only Weekly
Weekly $45.00	Weekly $60.00	Weekly $70.00	Weekly $85.00

A provider search can be conducted at http://www.dss.virginia.gov/facility/search/cc.cgi to determine the facility type (Level 1 or Level 2).

"Family day home" means a child day program offered in the residence of the vendor or the home of any of the children in care for one through 12 children under the age of 13, exclusive of the vendor’s own children and any children who reside in the home, when at least one child receives care for compensation.

"Child day center" means a child day program offered to two or more children under the age of 13 in a facility that is not the residence of the vendor or of any of the children in care or 13 or more children at any location.

SUFFOLK Child Care Maximum Reimbursement Rates Worksheet

MMR rates are locality specific. Child Care providers shall receive the MRR specific to the locality in which the provider is located. , i.e. if a foster child resides in Virginia Beach and receives Child Care services through a provider in Chesapeake, the provider’s rate will be based on the MRR for Chesapeake.

Answer the following questions about the provider and child in order to determine the maximum reimbursement rate. (Note: The provider MUST be licensed.):

Check One:	Level 1 Provider	Level 2 Provider

Unregulated vendors including in-home vendors (in-home vendors are paid minimum wage not to exceed Level 1 MRR for # of children in care)
Voluntarily Registered Family Day Homes
Religiously-Exempt Day Centers
Local Government-Approved Recreation Programs
Certified Preschools
Licensed Family Day Homes
Licensed Child Day Centers (including Short-Term Child Day Centers)
Licensed Family Day System-Approved Family Day Homes
Department of Education-Approved Child Care Programs
Child Care Centers run by the United States Department of Defense

Check One:	Check One:

Family Day Home	Child Day Center	Family Day Home	Child Day Center

Check One:	Check One:	Check One:	Check One:
Infant – Birth to 16 mths	Infant – Birth to 16 mths	Infant – Birth to 16 mths	Infant – Birth to 16 mths
Weekly $80.00	Weekly $110.00	Weekly $140.00	Weekly $145.00
Full Day (Part-Time Only)	Full Day (Part-Time Only)	Full Day (Part-Time Only)	Full Day (Part-Time Only)
$16.00	$22.00	$28.00	$29.00
Toddler – 16 mths to 24 mths	Toddler – 16 mths to 24 mths	Toddler – 16 mths to 24 mths	Toddler – 16 mths to 24 mths
Weekly $75.00	Weekly $100.00	Weekly $125.00	Weekly $145.00
Full Day (Part-Time Only)	Full Day (Part-Time Only)	Full Day (Part-Time Only)	Full Day (Part-Time Only)
$15.00	$20.00	$25.00	$29.00
Preschool – 24 mths to 5 yrs	Preschool – 24 mths to 5 yrs	Preschool – 24 mths to 5 yrs	Preschool – 24 mths to 5 yrs
Weekly $75.00	Weekly $85.00	Weekly $95.00	Weekly $130.00
Full Day (Part-Time Only)	Full Day (Part-Time Only)	Full Day (Part-Time Only)	Full Day (Part-Time Only)
$15.00	$17.00	$19.00	$26.00
School Age – 5+ (attending)	School Age – 5+ (attending)	School Age – 5+ (attending)	School Age – 5+ (attending)
Weekly $75.00	Weekly $80.00	Weekly $85.00	Weekly $90.00
Full Day (Part-Time Only)	Full Day (Part-Time Only)	Full Day (Part-Time Only)	Full Day (Part-Time Only)
$15.00	$16.00	$17.00	$18.00
Before/After Only Weekly	Before/After Only Weekly	Before/After Only Weekly	Before/After Only Weekly
Weekly $55.00	Weekly $55.00	Weekly $80.00	Weekly $70.00

A provider search can be conducted at http://www.dss.virginia.gov/facility/search/cc.cgi to determine the facility type (Level 1 or Level 2).

"Family day home" means a child day program offered in the residence of the vendor or the home of any of the children in care for one through 12 children under the age of 13, exclusive of the vendor’s own children and any children who reside in the home, when at least one child receives care for compensation.

"Child day center" means a child day program offered to two or more children under the age of 13 in a facility that is not the residence of the vendor or of any of the children in care or 13 or more children at any location.

Justification for Exceeding Child Care Maximum Reimbursable Rate Worksheet

Caretaker will pay the difference between the Maximum Reimbursable Rate and the Agreed upon Rate.

If the LDSS has made a diligent effort to secure child care at or lower than the maximum reimbursable rate and cannot locate a provider willing to accept that rate, the LDSS may choose to pay more if it is determined to be a reasonable cost. Reasonableness is determined based on the considerations used in selecting the provider. Providers whose costs cannot be justified as “reasonable” in comparison to costs charged by similar providers should generally not be used. The service worker shall document in OASIS the efforts made to secure the maximum reimbursable rate and factors used to determine reasonable cost.

Check all that apply:

Child Care provider was contacted on and efforts were made for provider to accept the Maximum Reimbursable Rate. Comments:

A search for child day care was conducted at http://www.dss.virginia.gov/facility/search/cc.cgi and the following zip codes were searched (include caregiver(s)’ home and work zip codes) in an attempt to locate other providers that are willing to accept the Maximum Reimbursable Rate.

No similar providers could be found. Reason:

The following Child Care providers were contacted and their costs are comparable to the selected provider as listed below:

Provider	Phone #	Rate
$
$
$
$

For children with special needs, payment of up to two times the MRR for the child’s age is allowed when it is appropriate as determined by the local department in consultation with the parent, vendor, and appropriate professional. Details of this consultation must be recorded in OASIS.

The child has a documented special need. Written documentation of this special need from an appropriate professional is attached.

This child requires payment above the Maximum Reimbursement Rate for the following reasons: