Forms

Consent for Release of Information and Referral - 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.

Preschool (3-5 years) Development and Routine

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.

Infant/Toddler (birth to 36 months) Development and Routine

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.

Injury Report Form

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.

Notice of Exposure to Communicable Disease

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.

Exclusion Form for Suspected Illness or Communicable Disease

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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