Title Page
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Conducted on
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Prepared by
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Type of Facility
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Name of Applicant:
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Date of Survey:
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Persons Living in Home (including Applicant) / Birthday / Relationship
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Number of chlldren in care under 18 months:
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Number of chlldren in care 18 months to 2 1/2 years:
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Number of children in care 2 1/2 years to Kindergarten:
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Number of children in care Kindergarten to 14 years:
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Number of children in care 14 to 16 years:
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CHECKLIST
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1. Number of children in care meets State of Kansas child care regulations
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2. Other employees in child care facility?
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How many:
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3. Emergency numbers are listed by or on the phone
4. The following information is available for each child:
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a. Name, address, and place of employment of parents
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b. Health assessments for children in care
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c. Parental permission for emergency care
5. Health certificates for:
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a. Provider
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b. All family members living in the home
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c. All employees
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6. Dog(s), cat(s) have current rabies shot.
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How many pets:
7. Completed plans for:
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a. Evacuating children in case of fire.
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b. Shelter for children in case of tornado.
8. The home:
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a. Is safe and free of hazards
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b. Has second exit readily available from first floor
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c. Has fire extinguisher in the kitchen
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d. Has medication, household poisons, sharp knives and scissors stored out of reach of children
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e. Has gas stoves/space heaters properly vented and guarded
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f. Has electrical outlets covered
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g. Has approved fire inspection
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Select date
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9. Meals for children in care are prepared within the facility
10. Outdoor play area:
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a. Is fenced
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b. Is free of hazards such as broken glass, broken toys or play equipment
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c. Play equipment is anchored firmly in the ground (as necessary)
11. Transportation:
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a. Transporting vehicle is covered by accident and liability insurance as required by State of Kansas Child Care Regulations
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b. Driver is over 18 years of age with a valid driver's license
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c. Appropriate individual restraints are used for each child transported
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d. Parental release forms for each child
12. Water Safety - Check if Applicable
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a. In-ground pool
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b. Above ground pool with at least four feet above ground (steps are removed from the pool when it is not in use)
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c. A five foot high fence separates the pool from the play area
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d. Wading pool (water is changed daily)
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Full Compliance
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Violations attached
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I certify that I have read and understand this completed form and that all information is true and correct. I understand that it is my responsibility to remain in compliance. I will notify the City when I discontinue child care or move from present address.
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Signature of Provider: