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Reset FormEXTENSION SITE QUESTIONNAIRE FOR OUTPATIENT PHYSICAL / OCCUPATIONAL / SPEECH THERAPY State Form 55642 (714) Indiana State Department of HealthDivision of Acute Pre-instructions:1. Answer
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Anyone who is planning to apply for an extension site needs to fill out the extension site questionnaire. This includes individuals or organizations seeking permission to create an extension site for various purposes such as research, education, business expansion, or community services.
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Extension site questionnaire is a form used to gather information about additional locations where a business operates.
Any business with additional locations or extension sites is required to file the extension site questionnaire.
Extension site questionnaire can be filled out online or by submitting a paper form with accurate information about the additional locations.
The purpose of extension site questionnaire is to ensure that businesses are accurately reporting all of their additional locations for regulatory and tax purposes.
Businesses must report the address, contact information, and operational details of each extension site on the questionnaire.
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