Spark Rating Renewal Form #4 Collaborative Continuous Quality Improvement Activities

Complete this form to renew your Spark rating if you have chosen Option 4, Collaborative Continuous Quality Improvement Activities. This form is to document goals achieved as a result of collaboration with a professional from an outside agency such as a Quality Improvement Specialist, mentor or coach. Information about rating renewal can be found at: https://oregonspark.org/current-participants/

Date * +

Program Name *

Provider Name *

License Number

Not Licensed

Current Star Rating *

Contact Number *

Phone Type

Cell

Office

Home

Email Address *

Name of Person Completing Form (if different)

Name of the Quality Improvement Specialist (QIS)/coach/mentor *

Phone # of QIS/coach/mentor *

When did you begin working with them? (approximate date is OK) *

Email Address of QIS/coach/mentor *

What types of goals were identified? For example, changes to the program environment, new or updated policies, changes in program practices. Check all that apply below. *

Please enter the type of goals if you selected "Other"

Describe how you achieved one goal in your program. Please Include photos if applicable and attach additional pages if necessary. *

Upload photos if applicable. You can upload up to 5 files

Which Spark domain(s) did this fall under? *

Signature *

clear

Date of Completion * +

Learning & Development	Health & Safety
Personnel Qualifications	Family Partnerships
Administration & Business Practices