Healthy Childcare Consultants, Inc.

SAMPLE FORMS FOR EARLY CARE
AND EDUCATION PROGRAMS

The forms listed on this page are examples only! Content of each form is based on national recommendations and requirements, and sample forms from other early care and education programs.

You are welcome to download these forms as examples for your own program. The individual forms may not include all the information needed for your specific program. Please carefully review all related Federal, state, and local requirements, as well as written policies for your program; then, you may modify these forms to meet the needs of your program.

Training Evaluation Forms

A generic form to be used to evaluate your training sessions, regardless of topic. Specific pre/post evaluation forms are also available for each of the available Staff and Parent Training Programs. (Click here to see training topics.) Please refer to the specific training page to download these documents.

Click here to download this generic form in English, or Spanish.

Basic First Aid Kit Checklist ( English - Revised)
Basic First Aid Kit Checklist (Spanish)

Disaster Preparedness Supply Checklist (English)
Disaster Preparedness Supply Checklist (Spanish)

Most authorities recommend preparing for three or more days (72 hours). Begin with a basic list of supplies; then work with a team to review and complete the list so that all children’s needs are met.

Injury Reporting

Administration of Medication
Document parent authorization and administration of medication.

Daily Health Check (English - Revised)

Staff should complete a visual check of each child upon arrival and before the parent leaves. A child who appears to be ill may be sent home or to the doctor/clinic as appropriate.

Sample Emergency Poster (English - Revised)
Sample Emergency Poster (Spanish)

Modify to create individualized posters for each classroom or nursery.

Community Assessment Questionnaire (English - Revised)
Community Assessment Questionnaire (Spanish)

This questionnaire may be modified and used to collect data from the target population; resulting information may supplement other community assessment data.

Sample forms on additional topics may be available. Contact Charlotte Hendricks for details.

You are welcome to download these posters for use in your program. If you would like to purchase hard copies, please contact Dr. Charlotte Hendricks. These or other posters can be printed, modified or created for specific program needs. Contact Dr. Hendricks to discuss specific needs for your program. Posters are available in English or Spanish.

Choking Hazards Poster

Washing Hands Poster

Emergency Posters

These are examples. Please modify to meet your program needs. Tornado or Severe Weather, Utility Disruption, Potentially Violent Situation, Chemical - Biological or Hazardous Material, Earthquake, Flooding, Fire.