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Common Child Care Forms

ADA Title III Flowchart: When Are You Required to Admit a Child with a Disability? (2002) General information about the Americans with Disabilities Act (ADA) as it pertains to child care programs.
C.C.A attendance forms 470-3872 Used to track the times in and out for children who are having their child care paid for by DHS through child care assistance.
C.C.A Agreement 470-3871 Form that providers fill out prior to being approved as eligible to provide child care assistance care. It lists your rates and the rules you must abide by in order to provide care through child care assistance.
Child Care Provider Physical Examination Report 470-5152 Form for Child Development Home providers requires health care providers to screen child care providers and all household members for health concerns, immunization status and other communicable diseases. Effective November 1, 2013 all physical exams must be documented on this form and kept in provider files.
Child Development Home Capacity Chart A helpful visual tool for Registered Child Development Homes regarding their capacity limits.
Child Development Home Capacity Worksheet with Explainations Helpful worksheet for Child Development Homes to use to determine the number of allowed children in care.
Consents and Releases For any type of provider to use. Parents complete the form about who is authorized to pick up a child, what type of field trips are approved, and a photo release. This form should be kept in the child’s file at the child care program.
DHS Child Care Assistance More information from DHS regarding child care assistance rates.
DHS Criminal History Record Check Form B DHS form for criminal and child abuse checks to be conducted for homes and centers.
DHS Report of Suspected Child Abuse 470-0665 This form may be used as the written report which the law requires all mandated reporters to file with the Department of Human Services following an oral report of suspected child abuse. Submit the completed form within 48 hours of making the oral report with the Child Abuse Hotline at 1-800-362-2178
Electrical Outlet Safety Handout Electrical products are responsible for millions of injuries, deaths and fires each year. 75% of victims of electrical outlet accidens are young children. Read more on this helpful handout about what you can do to help prevent accidents.
Emergency Contact Form Required for a registered child development home. It lists the phone numbers for fire, paramedic, poison control, and each child’s parents, doctor, and emergency contact.

Emergency Plan Diagram

Emergency Plan Map

Required for a registered child development home. You write and draw your plan in case of fire or tornado and where your outside meeting place is.

Emergency Preparedness Plan Homes

Emergency Preparedness Plan Centers

Use these word friendly forms for your  Quality Rating System (QRS) application. Having an emergency preparedness plans allows programs to ensure all steps are taken to prepare them for any emergency situation that may arise.
Fire & Tornado Symbol

Fire and Tornado symbols may be used as visual aids to help children understand the required written emergency plans posted by the primary and secondary exits in a Registered Child Development Home.

Getting Started A 19 page document from Redleaf National Institute with information about starting a family child care business.
Immunization Exemption Form Form parents complete if they refuse to immunize their children because of religion or doctor recommendation.
Injury Report Form Form from Healthy Child Care Iowa for child care staff or registered child development home to use to document an injury or accident. One copy is to be kept in the child’s file and one copy given to the parent or guardian.
Medication Record Form to be completed by the parent and provider when an enrolled child is given any medicine, topical cream, sunscreen, diaper ointment, breathing treatment, etc. Parent signature is required.
Model Child Care Health Policies Revised and updated 5th edition is a practical tool for adoption and implementation of best practices for health and safety in group care settings for young children.
Monthly Fire Drills Smoke Alarms Tornado Drills Form to document when provider has practiced monthly fire/tornado drills and changed batteries in smoke alarms.
Physicians Statement Health Form Form to be used by child care provider and copy kept in provider files
Reg. Guidelines comm143 Child Development Home Registration Guidelines A 101 page document listing detailed rules and regulations concerning home registration.
Rules 441-110 A 13 page document listing guidelines for rules and regulations.
School Age Health Status Forms Packet of required information to be kept in the children’s file for each child enrolled.
Smoke Free Air Signs A direct link to the Iowa Department of Health Smoke Free Air Act information including a link to print signs.
Toothbrushing Tool A helpful step by step guide on toothbrushing in child care.
Veterinary Health Certificate 470-5153 DHS annual health examination by a licensed veterinarian form for dog, cat and/or pet birtds in Registered Child Development Home. Form effective November 1st and must be maintained in provider files.