Perf-Based Stds, Adult Corr. Inst. 5th ed March 2020

Appendix G

Self-Evaluation Report

The Self-Evaluation Report is required for all agencies undergoing initial accreditation and it is optional for those undergoing reaccreditation. It must be submitted to ACA six weeks prior to your audit. If you would like to receive this document electronically, or if you have any questions, please contact your Accreditation Specialist.

Agency/Facility:

City/State:

Manual/Edition:

Supplement:

I certify that this agency has achieved 100 percent compliance with all applicable mandatory standards and at least 90 percent compliance with non-mandatory standards.

Name_ ______________________________________________________________________________

Title_________________________________________________________________________________

Date_ _______________________________________________________________________________

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