Child Health Online

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.

Injury Reporting

Administration of Medication
Document both parent authorization and administration of medication.

Daily Health Check
Caregiver should do 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
This is an example of a poster to be used in Head Start or other childcare classrooms or homes. Individualize posters for each classroom or nursery.

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

Emergency Supplies
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.

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

HEALTH AND SAFETY POSTERS

You are welcome to download these posters for use in your program. These posters were scanned as 11" x 8" pages, but you may wish to enlarge them. If you have difficulty downloading or printing these posters, and need a hard copy, please contact Dr. Charlotte Hendricks. These or other other posters can be printed, modified or created for specific program needs. Contact Dr. Hendricks to discuss any specific or special needs you might have.

Choking Hazards Poster

Washing Hands Poster

Emergency Posters

Tornado or Severe Weather, Utility Disruption, Potentially Violent Situation, Chemical - Biological or Hazardous Material, Earthquake, Flooding, Fire. To download all of the emergency posters in English, click here. These are samples only. Please modify to meet your program needs. Also available in Spanish.