{"id":563,"date":"2023-01-09T14:34:02","date_gmt":"2023-01-09T19:34:02","guid":{"rendered":"https:\/\/www.mthtwv.com\/mcs\/?page_id=563"},"modified":"2026-05-01T13:44:04","modified_gmt":"2026-05-01T17:44:04","slug":"forms-for-providers","status":"publish","type":"page","link":"https:\/\/www.mthtwv.com\/mcs\/forms-for-providers\/","title":{"rendered":"Additional Provider Forms"},"content":{"rendered":"<div class=\"boldgrid-section\">\n<div class=\"container\">\n<div class=\"row\">\n<div class=\"col-lg-12 col-md-12 col-xs-12 col-sm-12\">\n<h3 class=\"\">Provider Forms<\/h3>\n<h4 class=\"\">General Forms (No ECE Number)<\/h4>\n<ul class=\"\">\n<li><a title=\"Authorization for Protective Services Record Checks\" href=\"https:\/\/bfa.wv.gov\/media\/6971\/download?inline\" target=\"_blank\" rel=\"noopener\">Authorization for Protective Services Record Checks<\/a><\/li>\n<li><a href=\"https:\/\/dhhr.wv.gov\/bcf\/ece\/DocumentSearch\/2018%20Informal-Relative%20Checklist.pdf\" target=\"_blank\" rel=\"noopener\">2018 Informal-Relative Checklist.pdf<\/a><\/li>\n<li><a href=\"https:\/\/dhhr.wv.gov\/bcf\/ece\/DocumentSearch\/DISASTER%20PLANNING%20FORM%20-%20CENTER%20&amp;%20FACILITY%20(1).pdf\" target=\"_blank\" rel=\"noopener\">Disaster Planning Form &#8211; Center &amp; Facility<\/a><\/li>\n<li><a href=\"https:\/\/dhhr.wv.gov\/bcf\/ece\/DocumentSearch\/DISASTER%20PLANNING%20FORM%20-%20HOME,%20INFORMAL,%20RELATIVE.pdf\" target=\"_blank\" rel=\"noopener\">Disaster Planning Form &#8211; Home, Informal, Relative<\/a><\/li>\n<li><a href=\"https:\/\/dhhr.wv.gov\/bcf\/ece\/DocumentSearch\/DISASTER%20PLANNING%20FORM%20-%20HOME,%20INFORMAL,%20RELATIVE%20and%20IN-HOME.pdf\" target=\"_blank\" rel=\"noopener\">Disaster Planning Form &#8211; Home, Informal, Relative &amp; In-Home<\/a><\/li>\n<li><a href=\"https:\/\/dhhr.wv.gov\/bfa\/ece\/Documents\/Provider%20Medical%20052022.pdf\" target=\"_blank\" rel=\"noopener\">Child Care Provider Medical Report<\/a><\/li>\n<li><a href=\"https:\/\/www.cdc.gov\/vaccines\/hcp\/imz-schedules\/downloads\/child\/0-18yrs-child-combined-schedule.pdf\" target=\"_blank\" rel=\"noopener\">Recommended Child and Adolescent Immunization Schedule<\/a><\/li>\n<li><a href=\"https:\/\/dhhr.wv.gov\/bcf\/ece\/DocumentSearch\/REQUEST%20TO%20AMEND%20APPLICATION%20-%202022.pdf\" target=\"_blank\" rel=\"noopener\">Request to Amend Application &#8211; 2022<\/a><\/li>\n<li><a href=\"https:\/\/www.mthtwv.com\/mcs\/wp-content\/uploads\/Documents\/childcare\/providers\/forms\/Provider-Request-Form-for-Technical-Assistance.pdf\" target=\"_blank\" rel=\"noopener\">Technical Assistance Request Form<\/a><\/li>\n<li><a href=\"https:\/\/bfa.wv.gov\/page\/tiered-reimbursement\" target=\"_blank\" rel=\"noopener\">Tiered Reimbursement<\/a><\/li>\n<\/ul>\n<h4 class=\"\">ECE Numbered Forms<\/h4>\n<ul class=\"\">\n<li><a href=\"https:\/\/dhhr.wv.gov\/bcf\/ece\/DocumentSearch\/ECE-CC-%200162B%2042018%20Change%20of%20Information%20Notification.pdf\" target=\"_blank\" rel=\"noopener\">ECE-CC-0162B Change of Information Notification<\/a><\/li>\n<li><a title=\"ECE-CC-1B New Employment Verification\" href=\"https:\/\/www.wvdhhr.org\/choices\/for-families\/forms\/New%20Employment%20Verification%20Form.pdf\" target=\"_blank\" rel=\"noopener\">ECE-CC-1B New Employment Verification<\/a><\/li>\n<li><a href=\"https:\/\/bfa.wv.gov\/media\/6936\/download?inline\" target=\"_blank\" rel=\"noopener\">ECE-CC-3 Child Health Assessment<\/a><\/li>\n<li><a href=\"https:\/\/dhhr.wv.gov\/bcf\/ece\/DocumentSearch\/ECE-CC-3B%20Statement%20of%20goodhlth%204%202014.pdf\" target=\"_blank\" rel=\"noopener\">ECE-CC-3B Statement of Good Health<\/a><\/li>\n<li><a href=\"https:\/\/dhhr.wv.gov\/bcf\/ece\/DocumentSearch\/ECE-CC-7%20Provider%20Information%20Form%203%202013.pdf\" target=\"_blank\" rel=\"noopener\">ECE-CC-7 Provider Information Form<\/a><\/li>\n<li><a href=\"https:\/\/dhhr.wv.gov\/bcf\/ece\/DocumentSearch\/ECE-CC-8A%20PS%20Check%203%202014.pdf\" target=\"_blank\" rel=\"noopener\">ECE-CC-8A PS Check<\/a><\/li>\n<li><a href=\"https:\/\/dhhr.wv.gov\/bcf\/ece\/DocumentSearch\/ECE-CC-8B%2003-10%20Statement%20of%20Criminal%20Record%2011%202013.pdf\" target=\"_blank\" rel=\"noopener\">ECE-CC-8B Statement of Criminal Record<\/a><\/li>\n<li><a href=\"https:\/\/www.mthtwv.com\/mcs\/wp-content\/uploads\/Documents\/childcare\/providers\/forms\/Request-for-Payment-Child-Care-Services-ECE-CC-10A-0124.pdf\" target=\"_blank\" rel=\"noopener\">ECE-CC-10A Request for Payment Child Care Services<\/a><\/li>\n<li><a href=\"https:\/\/www.mthtwv.com\/mcs\/wp-content\/uploads\/Documents\/childcare\/providers\/forms\/ECE-CC-10G-Child-Care-Attendance-Sheet-2026.pdf\" target=\"_blank\" rel=\"noopener\">ECE-CC-10G Child Care Attendance Sheet<\/a><\/li>\n<li><a href=\"https:\/\/dhhr.wv.gov\/bcf\/ece\/DocumentSearch\/ECE-CC-10%20K%20Child%20Care%20and%20Responsible%20Pet%20Ownership%203%202014.pdf\" target=\"_blank\" rel=\"noopener\">ECE-CC-10K Child Care and Responsible Pet Ownership<\/a><\/li>\n<li><a title=\"ECE-CC-10J Pet Acknowledgement Form\" href=\"https:\/\/bfa.wv.gov\/media\/7061\/download?inline\" target=\"_blank\" rel=\"noopener\">ECE-CC-10J Pet Acknowledgement Form<\/a><\/li>\n<li><a href=\"https:\/\/dhhr.wv.gov\/bcf\/ece\/DocumentSearch\/ECE-CC-10E%20Emergency%20Info%20Form%2062018.pdf\" target=\"_blank\" rel=\"noopener\">ECE-CC-10E Emergency Info Form<\/a><\/li>\n<li><a href=\"https:\/\/dhhr.wv.gov\/bcf\/ece\/DocumentSearch\/ECE-CC-14%20BLetter%20of%20Intent%20and%20Needs%20Assessment_Facility_060718.pdf\" target=\"_blank\" rel=\"noopener\">ECE-CC-14 Letter of Intent and Needs Assessment<\/a><\/li>\n<li><a href=\"https:\/\/dhhr.wv.gov\/bcf\/ece\/DocumentSearch\/Letter%20of%20Intent%20and%20Needs%20Assessment_Facility%20final.pdf\" target=\"_blank\" rel=\"noopener\">ECE-CC-14 Letter of Intent and Needs Assessment (Final)<\/a><\/li>\n<li><a href=\"https:\/\/dhhr.wv.gov\/bcf\/ece\/DocumentSearch\/ECE-CC-14A%20Facility%20Info%20Packet%204%202014.pdf\" target=\"_blank\" rel=\"noopener\">ECE-CC-14A Facility Info Packet<\/a><\/li>\n<li><a href=\"https:\/\/dhhr.wv.gov\/bcf\/ece\/DocumentSearch\/ECE-CC-15%20Facility%20Application%204%202014.pdf\" target=\"_blank\" rel=\"noopener\">ECE-CC-15 Facility Application<\/a><\/li>\n<li><a href=\"https:\/\/dhhr.wv.gov\/bcf\/ece\/DocumentSearch\/ECE-CC-23%20Fire%20Escape%20Plan%208%202016.pdf\" target=\"_blank\" rel=\"noopener\">ECE-CC-23 Fire Escape Plan<\/a><\/li>\n<li><a href=\"https:\/\/dhhr.wv.gov\/bcf\/ece\/DocumentSearch\/ECE-CC-25%20Medication%20Permission%20Slips%204%202014.pdf\" target=\"_blank\" rel=\"noopener\">ECE-CC-25 Medication Permission Slips<\/a><\/li>\n<li><a title=\"ECE-CC-26 Child Care Provider Incident Report Form\" href=\"https:\/\/bfa.wv.gov\/media\/7056\/download?inline\" target=\"_blank\" rel=\"noopener\">ECE-CC-26 Child Care Provider Incident Report Form<\/a><\/li>\n<\/ul>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<div class=\"pvc_clear\"><\/div>\n<p id=\"pvc_stats_563\" class=\"pvc_stats all  \" data-element-id=\"563\" style=\"\"><i class=\"pvc-stats-icon medium\" aria-hidden=\"true\"><svg aria-hidden=\"true\" focusable=\"false\" data-prefix=\"far\" data-icon=\"chart-bar\" role=\"img\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" viewBox=\"0 0 512 512\" class=\"svg-inline--fa fa-chart-bar fa-w-16 fa-2x\"><path fill=\"currentColor\" d=\"M396.8 352h22.4c6.4 0 12.8-6.4 12.8-12.8V108.8c0-6.4-6.4-12.8-12.8-12.8h-22.4c-6.4 0-12.8 6.4-12.8 12.8v230.4c0 6.4 6.4 12.8 12.8 12.8zm-192 0h22.4c6.4 0 12.8-6.4 12.8-12.8V140.8c0-6.4-6.4-12.8-12.8-12.8h-22.4c-6.4 0-12.8 6.4-12.8 12.8v198.4c0 6.4 6.4 12.8 12.8 12.8zm96 0h22.4c6.4 0 12.8-6.4 12.8-12.8V204.8c0-6.4-6.4-12.8-12.8-12.8h-22.4c-6.4 0-12.8 6.4-12.8 12.8v134.4c0 6.4 6.4 12.8 12.8 12.8zM496 400H48V80c0-8.84-7.16-16-16-16H16C7.16 64 0 71.16 0 80v336c0 17.67 14.33 32 32 32h464c8.84 0 16-7.16 16-16v-16c0-8.84-7.16-16-16-16zm-387.2-48h22.4c6.4 0 12.8-6.4 12.8-12.8v-70.4c0-6.4-6.4-12.8-12.8-12.8h-22.4c-6.4 0-12.8 6.4-12.8 12.8v70.4c0 6.4 6.4 12.8 12.8 12.8z\" class=\"\"><\/path><\/svg><\/i> <img loading=\"lazy\" decoding=\"async\" width=\"16\" height=\"16\" alt=\"Loading\" src=\"https:\/\/www.mthtwv.com\/mcs\/wp-content\/plugins\/page-views-count\/ajax-loader-2x.gif\" border=0 \/><\/p>\n<div class=\"pvc_clear\"><\/div>\n","protected":false},"excerpt":{"rendered":"<p>Provider Forms General Forms (No ECE Number) Authorization for Protective Services Record Checks 2018 Informal-Relative Checklist.pdf Disaster Planning Form &#8211; Center &amp; Facility Disaster Planning Form &#8211; Home, Informal, Relative<\/p>\n<div class=\"read-more\"><a class=\"btn button-secondary\" href=\"https:\/\/www.mthtwv.com\/mcs\/forms-for-providers\/\">Read More<\/a><\/div>\n<div class=\"pvc_clear\"><\/div>\n<p id=\"pvc_stats_563\" class=\"pvc_stats all  \" data-element-id=\"563\" style=\"\"><i class=\"pvc-stats-icon medium\" aria-hidden=\"true\"><svg aria-hidden=\"true\" focusable=\"false\" data-prefix=\"far\" data-icon=\"chart-bar\" role=\"img\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" viewBox=\"0 0 512 512\" class=\"svg-inline--fa fa-chart-bar fa-w-16 fa-2x\"><path fill=\"currentColor\" d=\"M396.8 352h22.4c6.4 0 12.8-6.4 12.8-12.8V108.8c0-6.4-6.4-12.8-12.8-12.8h-22.4c-6.4 0-12.8 6.4-12.8 12.8v230.4c0 6.4 6.4 12.8 12.8 12.8zm-192 0h22.4c6.4 0 12.8-6.4 12.8-12.8V140.8c0-6.4-6.4-12.8-12.8-12.8h-22.4c-6.4 0-12.8 6.4-12.8 12.8v198.4c0 6.4 6.4 12.8 12.8 12.8zm96 0h22.4c6.4 0 12.8-6.4 12.8-12.8V204.8c0-6.4-6.4-12.8-12.8-12.8h-22.4c-6.4 0-12.8 6.4-12.8 12.8v134.4c0 6.4 6.4 12.8 12.8 12.8zM496 400H48V80c0-8.84-7.16-16-16-16H16C7.16 64 0 71.16 0 80v336c0 17.67 14.33 32 32 32h464c8.84 0 16-7.16 16-16v-16c0-8.84-7.16-16-16-16zm-387.2-48h22.4c6.4 0 12.8-6.4 12.8-12.8v-70.4c0-6.4-6.4-12.8-12.8-12.8h-22.4c-6.4 0-12.8 6.4-12.8 12.8v70.4c0 6.4 6.4 12.8 12.8 12.8z\" class=\"\"><\/path><\/svg><\/i> <img loading=\"lazy\" decoding=\"async\" width=\"16\" height=\"16\" alt=\"Loading\" src=\"https:\/\/www.mthtwv.com\/mcs\/wp-content\/plugins\/page-views-count\/ajax-loader-2x.gif\" border=0 \/><\/p>\n<div class=\"pvc_clear\"><\/div>\n","protected":false},"author":3,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"crio-premium-page-header-override":null,"crio-premium-page-header-select":"none","crio-premium-page-header-featured-image-background":"0","crio-premium-page-header-background":"","om_disable_all_campaigns":false,"_themeisle_gutenberg_block_has_review":false,"footnotes":""},"class_list":["post-563","page","type-page","status-publish"],"aioseo_notices":[],"a3_pvc":{"activated":true,"total_views":4833,"today_views":0},"publishpress_future_action":{"enabled":false,"date":"2026-06-18 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