SAMPLE FORMS - IACCRR

1 1. SAMPLE . FORMS . Familiarize yourself with Indiana's Rules & Regulations for Family Child Care Providers. You will notice many of these FORMS include information which exceeds the information required by the Indiana code. Keep on file all required documentation as listed on the following pages. Your licensing consultant will ask for this documentation at the time of his/. her visit. FORMS marked SAMPLE may be substituted. FORMS listed with an * asterisks should not be substituted. 2. Primary Provider (Applicant for Licensure). Required FORMS These FORMS are located in your Application Packet (Located in the front pocket of this manual).

2 *Application _____. (Send to licensing consultant). *Attestation Statement _____. (Send to licensing consultant). *National Criminal History Check _____. (complete process, results will be sent to licensing consultant). *Consent for Release Crim Hist for homes centers and ministries (Send to licensing consultant) _____. *Taxpayer Identification Request W-9 _____. (Only I taking CCDF vouchers). You must send in copies of birth certificates, driver's license's, or state 's for you, your spouse, workers or volunteers and other household members. You must also send in proof (copy of certificates) of Orienta- tion I and II and Safe Sleeping Practices and Reducing the Risk of SIDS.

3 In Child Care. You must also send in a copy of your High School Diploma or GED or College transcripts. *Denotes that you must use the state form provided in Family Child Care Orientation Training & Resource Manual the Prepared By: The Indiana Association for Child application Care packet Resource & Referral 3. Primary Provider (Applicant for Licensure). Required FORMS Continued form A Provider Medical Report _____. (Send to licensing consultant). form B Universal Precautions _____. ( form not needed if you have a certification card). *Five Panel Drug Screening _____. (Send Results to licensing consultant).

4 Education Requirements - this will be given to you at the first inspection visit * Contained in Application Packet 4 form A. S Family Child Care Home Provider Medical Report A. M To be completed by provider: Name of provider:_____. P Birth date:_____. Address:_____. L. I, _____, hereby authorize the physician or E certified nurse practitioner named below to release information to the Division of Family and Children, which is necessary for the child care provider's evaluation. F. Name of Physician/Nurse Practitioner Address O. R _____. M. S To be completed by physician or certified nurse practitioner: I.

5 Intradermal Tuberculin Test or Chest X-ray Results_____ Date_____. II. Does this person have any apparent disease or physical condition that would restrict them from caring for young children as a profession? Yes_____ No_____. If yes, please explain_____. _____. _____. III. Weight_____ Height_____. Blood Pressure_____. Comments: Signature of nurse practitioner or physician: _____Date_____. Family Child Care Orientation Training & Resource Manual Prepared By: The Indiana Association for Child Care Resource & Referral form B 5. Verification and Documentation S. of Universal Precautions Training A.

6 Date: M. P. I, _____, L. Acknowledge that I have received training in E. UNIVERSAL PRECAUTIONS on the above date. I un- derstand how to protect myself using the procedures F. of Universal Precautions taught to me. The teaching methods used were discussion plus demonstration O. and/or a video or film. R. Signature of Training Recipient: M. _____ S. Date of Training:_____. Trainer:_____. Source of Trainer's Universal Precautions Training: _____. _____. 6 form C. S Orientation for Staff or Volunteers A Name of Volunteer or Staff Person:_____. M 1. Complete Consent for Release Of Information for Criminal History Check for anyone over 18 years of age.

7 P Date sent to Licensing Consultant:_____. L 2. Start date:_____. E 3. Training before or within the first week of employment or volunteer work by the licensed provider 0n fire prevention and safety proce- dures: F _____ Show and explain evacuation plan _____ Show location of all smoke alarms and how they are tested during drills O _____ Show location of gas, electric, and water shut-off and how they work R _____ Show location of emergency phone numbers M _____ Show location of all fire extinguishers and how to use S 4. Training before or within the first month of employment or volunteer work on the following: _____ Review the home inspection checklist _____ Review procedures about confidential treatment of personal information about children in their care and their families _____ Procedures for preventing and detecting child abuse and neglect _____ Universal Precautions training 5.

8 First aid training before or within ninety (90) days of starting employment or volunteer work. Date of First Aid_____. 6. Training in Pediatric Cardiopulmonary Resuscitation (CPR). MUST BE COMPLETE BEFORE staff or volunteer are allowed to be left alone with children. Date of CPR_____. Family Child Care Orientation Training & Resource Manual Prepared By: The Indiana Association for Child Care Resource & Referral form D 7. Family Child Care Home Assistant/Volunteer Medical Report S. Name of provider:_____ A. Birth date:_____. Address:_____. M. P. I, _____, hereby authorize the physician or certified nurse practitioner named below to release information to L.

9 The Division of Family Resources, which is necessary for the Child care provider's evaluation. E. Name of Physician/Nurse Practitioner Address F. To be completed by physician or certified nurse O. Practitioner: R. I. Intradermal Tuberculin Test or Chest X-Ray Results_____Date_____ M. II. Does this person have any apparent disease or physical S. condition that would restrict them from caring for young children as a profession? Yes_____No_____. If yes, please ex- plain_____. _____. _____. III. Weight_____Height_____. Blood Pressure_____. Comments: 8 form E. S Verification and Documentation A of Universal Precautions Training M.

10 Date: P. L I, _____, E. Acknowledge that I have received training in UNIVERSAL PRECAUTIONS on the above date. I un- F derstand how to protect myself using the procedures of O Universal Precautions taught to me. The teaching methods used were discussion plus demonstration and/. R or a video or film. M. S Signature of Training Recipient: _____. Date of Training:_____. Trainer:_____. Source of Trainer's Universal Precautions Training: _____. _____. Family Child Care Orientation Training & Resource Manual Prepared By: The Indiana Association for Child Care Resource & Referral 9. SAMPLE FORMS to Help Document Requirements for Household Members Over Eighteen Years of Age form F Medical Report _____.