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Publications and Resources

Forms & Checklists for Early Care and Education Programs

Health and Safety Checklists

Special Needs

Consents

Child Care Health Consultants and Advocates

Communicable Disease

Injury

Child development

Policy

Other Forms


The Advocate Daily Encounter Form (ADEF) (PDF; 35KB; 1p)
Child Care Health Advocates (CCHAs) fill out an Advocate Daily Encounter Form (ADEF) every day they work as a Linkages CCHA. The purpose is the same as that of the DEF: to track the activities of Linkages CCHA and understand changes that occur as a result of their work in child care settings. The ADEF is the first form to track activities of CCHAs, and the research staff is looking forward to learning how services provided by CCHAs are effective in improving the health and safety of children in child care settings and their families.
The Advocate Daily Encounter Form (ADEF) was adapted from the DEF by the Child Care Health Linkages Evaluation Project.
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The Child Care Evaluation Worksheet (Record Review) (PDF; 69KB; 2pp)
The Child Care Evaluation Worksheet can be used by researchers, child care providers, or anyone interested in assessing a child care program for health and safety. Record reviews are valuable because they indicate areas in need for individual children as well as the group (such as immunization gaps or medical homes). Please note that review of children's health records in a child care setting by outside observers requires individual parent consent in California.
The Child Care Evaluation Worksheet was developed by the University of North Carolina, Quality Enhancement Project.
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Consent for Exchange of Information (PDF; 25KB; 1p)
This form provides parental permission for the exchange of relevant health, development and/or educational information between a Child Care Health Consultant (CCHC), the child care program staff and other individuals, programs or agencies that are working with the child and family in an effort to better understand and address their needs. This form is for use in situations where there is not a referral to services.
This form was developed through a collaboration between Abby J. Cohen, J.D. and CCHP.
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Consent for Release of Information and Referral (PDF; 162KB; 1p) Revised
This form provides parental permission for the release of health, development and/or educational information between the Child Care Health Consultant (CCHC), the child care program staff and other individuals, programs or agencies that are working with the child and family in an effort to better understand and address their needs. In addition, this form obtains parental permission for the referral to needed support services for the child and/or family.
This form was developed through a collaboration between Abby J. Cohen, J.D. and CCHP.
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Consent for Review of Staff Health Records (PDF; 26KB; 1p)
Child care facilities should have a health professional with experience and training in child care, known as a Child Care Health Consultant (CCHC), affiliated with their program. This form requests legal permission for CCHCs to review individual health records of child care providers/staff.
This form was developed through a collaboration between Abby J. Cohen, J.D. and CCHP.
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Consent for Services (PDF; 24KB; 1p)
This form provides parental permission for a child and/or family to receive health consultation services such as assessments, observations, screenings and consultations that will be provided onsite at the child care setting. It also permits sharing of the information between the child care staff and the health professional for the purpose of understanding and addressing the child's or family's needs.
This form was developed through a collaboration between Abby J. Cohen, J.D and CCHP.
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Continuum of Liability Exposure for CCHCs (PDF; 42KB; 1p)
Child Care Health Consultants engage in a variety of activities and each presents a possibility of liability exposure. Based on general legal principles and experience, some types of activities pose a greater degree of exposure than others. This list in this document will provide consultants with a sense of relative exposure resulting from the varied activities in which they might engage.
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The Daily Encounter Form (DEF) (PDF; 98KB; 1p)
Child Care Health Consultants (CCHCs) fill out the Daily Encounter Form (DEF) every day they work as a Linkages CCHC. The research team collects these DEFs to learn about the activities of CCHCs. Tracking the activities of the CCHCs will allow the researchers to understand changes that occur as a result of the CCHCs' work. The information gathered will also allow comparison of health consultation services between counties and will help researchers identify which aspects of health consultation services are most effective in improving the health and safety of children in child care settings and their families.
The Daily Encounter Form (DEF) was originally developed by the University of North Carolina, Quality Enhancement Project. The Child Care Health Linkages Evaluation Project adapted this form for use in California.
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Suspected Illness or Communicable Disease Exclusion Form (PDF; 131KB; 1p)

Formulario de exclusión por sospecha de enfermedad o de (PDF; 132KB;1p)

Communicating with parents about health concerns at child care is an important step in caring for an ill child. This form will help you report your observations to parents. It includes a list of signs and symptoms that indicate a need for medical attention.

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Health and Safety Checklist for Early Care and Education Programs: Based on Caring for Our Children National Health and Safety Performance Standards - Third Edition

The Health and Safety Checklist is a 112-item tool developed to assess key health and safety standards and identify ways to improve health and safety in early care and education (ECE) programs. The Checklist includes 72 out of the 138 key health and safety standards in Stepping Stones Third Edition. The Checklist was reviewed by an advisory committee of health and safety experts and pilot tested by child care health consultants. The Checklist is user-friendly, easy-to-understand and has links to the Caring for Our Children standards and other related resources. It can be used on a computer, electronic tablet or smart phone or printed on paper and filled out by hand. The User Manual provides background information and guidelines for rating each item.

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CCHP Health and Safety Checklist Summary (PDF;20.8KB;2pp)

The CCHP Health and Safety Checklist Summary is designed to be completed after a health and safety assessment in an early care and education program is conducted using the CCHP Health and Safety Checklist-Revised. The Summary Form is organized by subscale and there are three columns to complete for each subscale: # of standards (items) which meet the National Standards, # of standards (items) which do NOT meet the National Standards, and action steps needed to meet the National Standards.  
 
The last row is for the overall summary of the total # of items that meet the National Standards and total # of items that do NOT meet the National Standards. Lastly, there is a space to write notes and recommendations along with the date of the next assessment.

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CCHP Health and Safety Policies Checklist

The California Childcare Health Program Health and Safety Policies Checklist (2005) was developed to objectively assess written health and safety policies in early care and education programs. The Checklist can be used by child care providers or directors, child care health advocates, child care health consultants, health professionals, and researchers. It assesses the quality of written health and safety policies and helps child care and health professionals identify how to improve written policies and target interventions. The Checklist is based on the University of North Carolina of Chapel Hills's Quality Enhancement Project and the National Health and Safety Performance Standards (AAP, APHA, NRC, 2002).

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Infant/Toddler (birth to 36 months) Development and Routine (PDF; 45KB; 1p)

As a basis for meeting a child's health, behavioral and social needs in the child care setting, the file for each child should include a history form that is completed by the parent/guardian upon admission, preferably with assistance from the staff. This form addresses issues relevant to infants and toddlers only.

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Information Exchange on Children with Health Concerns (PDF; 64KB; 1p)

Working with a parent/guardian, a child care provider can obtain relevant information on a child's health and development from the child's health care provider in an effort to better understand and address the child's unique needs. This form authorizes the exchange of information. It is completed by the child care provider and signed by the parents, giving consent for release of such information from the health care provider to the child care provider.

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Injury Report Form (PDF; 26KB; 1p)
Formulario de informe de lesiones (PDF; 38KB; 1p) New!

It is important that all child care programs record any injury that requires first aid, such as a bandage or a cold compress. Planning for injuries, reporting injuries and eliminating hazards or conditions that cause injuries should be part of the overall plan to keep children safe while they are in child care. And by tracking injuries that happen, programs can look for patterns caused by hazardous conditions and identify problem areas before they cause serious injury. This form is to be used to ensure accurate tracking and appropriate follow-up of all serious incidents that occur in child care.

This form was developed by CCHP staff and is excerpted from Health and Safety in the Child Care Setting: Prevention of Injuries, A Curriculum for the Training of Child Care Providers, 2nd Ed. If you discover a child's injury, such as bruising, cuts or burns, and suspect child abuse, you are required to file a report with your local child protective services agency.

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Insect Repellent Consent (PDF; 37KB; 1p)
Permiso de padres o tutores para aplicar repelente de insectos al niño (PDF;89.9KB;ip) New!

Due to the presence of chemicals and the possibility of allergic reactions for some children exposed to insect repellents, this form provides parental consent to apply insect repellent while in the child care setting.

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Liability Exposure and Child Care Health Consultation (PDF; 105KB; 1p)

Child care health consultation is a new profession emerging out of an identified need to link the public health and child care fields together. As of yet, there exists no definitive consensus on the scope of this work or the standards of care that are expected of those who engage in the work. This document describes the most significant methods available for minimizing liability exposure in California.

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Medication Administration Form (PDF; 136KB; 2pp)

Formulario de administración de medicamentos (PDF; 138;2pp)

Child care programs must have a written policy for the use of any medication (prescription and nonprescription) that the facility keeps on hand to use with parental consent. This form documents such authorization of administration of medication for a child while in care. The reverse side of the form is a monthly medication log that allows the monitoring and tracking of medication dispensation.

For additional information about medication administration health policies, procedures and training see Caring for Our Children: National Health and Safety Standards: Guidelines for Out-of-Home Child Care Programs and/or contact the Healthline at (...) ...-.... (California Only).

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Notice of Exposure to Communicable Disease (PDF; 127KB; 1p)

This form will help you prepare a written notice to parents about their children's exposure to communicable disease. The notice will alert them to watch for signs and symptoms of the illness while maintaining confidentiality of the child or staff member who has the disease.

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Nutrition and Feeding Care Plan (PDF; 39KB; 2pp)

The development and implementation of a care plan for a child with feeding and/or nutritional issues should be determined by each child's unique needs. This form defines all members of the child's care team; specifies the communication approaches of the team members; details the strategies for appropriately caring for the child with special dietary and/or feeding concerns in group care settings, and identifies accommodations/modifications necessary while the child is in care.

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Preschool (3-5 years) Development and Routine (PDF; 44KB; 2pp)

As a basis for meeting a child's health, behavioral and social needs in the child care setting, the file for each child in care should include a history form completed by the parents/guardian upon admission, preferably with staff involvement. This form addresses issues relevant to preschoolers only.

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Quality Inclusive Child Care Checklist (PDF; 192KB; 2pp)

Quality care provides a safe and healthy learning environment that supports the social, physical, intellectual, creative and emotional development of all children. This checklist assists parents of children with disabilities or special needs in looking, listening and asking questions in the process of selecting the child care setting that best meets the needs of their child and family. It can also assist programs in identifying the necessary components of a quality inclusive child care setting as they evaluate their program and services provided.

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Seizure Care Plan (PDF; 98.6KB; 2pp)
Seizure Activity Log (PDF; 57KB; 1p)
Plan de asistencia al niño en caso de padecer un ataque (PDF, 79.7KB;2pp) New!
REGISTRO DE ACTIVIDADES EN CASO DE ATAQUES (PDF;19.9;1p)
New!

The development and implementation of a care plan for a child with a seizure disorder should be determined by each child's unique needs. This form defines all members of the child's care team; specifies the communication approaches of the team members; details the strategies for caring for a child who has had seizures, and how to meet his/her needs while in group care settings, and contains a seizure activity tracking log for while the child is in care.

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Special Health Care Plan (PDF; 36KB; 3pp)
Plan de asistencia especial de salud (PDF; 70.7KB;3pp) New!

The development and implementation of a care plan for a child with special health care needs should be determined by each child's unique needs. This form identifies all members of the child's care team; specifies the communication approaches of the team members; details the strategies for appropriately caring for the child with special health concerns in group care settings, and identifies accommodations/modifications necessary while the child is in care.

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Sun-Smart Policy (PDF; 44KB; 1p)
PERMISO DE LOS PADRES O TUTORES PARA APLICAR PROTECTOR SOLAR AL NIÑO (PDF; 37KB; 1p) New!

This policy ensures that all children and staff participating in a child care program are protected from skin damage caused by the harmful UVB and UVA rays of the sun throughout the year. On the reverse side is a parental consent form for permission to apply sunscreen while in the child care setting.

The policy was developed by CCHP; the consent portion was adapted from the California Early Childhood Sun Protection Curriculum.

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Toy Safety Checklist (PDF; 20KB; 1p)

Use this checklist to help keep children safe while using the learning equipment and materials provided in the child care settings.

This form was developed by CCHP staff and is excerpted from Health and Safety in the Child Care Setting: Prevention of Injuries, A Curriculum for the Training of Child Care Providers, 2nd Ed.

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CCHP Health and Safety Checklist--Revised
(PDF; 60KB; 7pp)
CCHP Health and Safety Checklist Summary
(PDF;20.8KB;2pp)
CCHP Health and Safety Policies Checklist
(PDF; 193KB; 13pp)
Quality Inclusive Child Care Checklist
(PDF; 192KB; 2pp)
Toy Safety Checklist
(PDF; 20KB; 1p)
Information Exchange on Children with Health Concerns
(PDF; 64KB; 1p)
Medication Administration Form
(PDF; 136KB; 2pp)
Formulario de administración de medicamentos (PDF; 138;2pp)
Nutrition and Feeding Care Plan
(PDF; 39KB; 2pp)
Seizure Care Plan
(PDF; 98.6KB; 2pp)
Plan de asistencia al niño en caso de padecer un ataque (PDF, 79.7KB;2pp) New!
Seizure Activity Log
(PDF; 57KB; 1p)
REGISTRO DE ACTIVIDADES EN CASO DE ATAQUES (PDF;19.9;1p) New!
Special Health Care Plan
(PDF; 36KB; 3pp)
Plan de asistencia especial de salud (PDF; 70.7KB;3pp) New!
Consent for Exchange of Information
(PDF; 25KB; 1p)
Consent for Review of Staff Health Records
(PDF; 26KB; 1p)
Consent for Services
(PDF; 24KB; 1p)
Insect Repellent Consent (PDF; 37KB; 1p) Permiso de padres o tutores para aplicar repelente de insectos al niño (PDF;89.9KB;ip) New!
Sun-Smart Policy
(PDF; 44KB; 1p)
PERMISO DE LOS PADRES O TUTORES PARA APLICAR PROTECTOR SOLAR AL NIÑO (PDF; 37KB; 1p) New!
The Advocate Daily Encounter Form (ADEF)
(PDF; 35KB; 1p)
The Child Care Evaluation Worksheet (Record Review)
(PDF; 69KB; 2pp)
Continuum of Liability Exposure for CCHCs
(PDF; 42KB; 1p)
The Daily Encounter Form (DEF)
(PDF; 35KB; 1p)
Liability Exposure and Child Care Health Consultation
(PDF; 105KB; 1p)
Exclusion Form for Suspected Illness or Communicable Disease
(PDF; 131KB; 1p)
Formulario de exclusión por sospecha de enfermedad o de (PDF; 132KB;1p)
Notice of Exposure to Communicable Disease
(PDF; 127KB; 1p)
Injury Report Form
(PDF; 26KB; 1p)
Formulario de informe de lesiones (PDF; 38KB; 1p) New!
Infant/Toddler (birth to 36 months) Development and Routine (PDF; 45KB; 1p)
Preschool (3-5 years) Development and Routine
(PDF; 44KB; 2pp)
Safe Sleep policy for Infants in Child Care
(PDF;180KB;2pp)
Normas de seguridad durante el sueño del bebé en el establecimiento de cuidado de niños (PDF; 187KB; 2pp)
Documentation of Health and Safety Training
(PDF;32.8KB;2pp)
Request for Permission to Reprint/Reproduce CCHP Health and Safety Materials
(PDF;46.1KB;2pp)
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