• Type of Facility

  • Name of Applicant:

  • Date of Survey:

  • Persons Living in Home (including Applicant) / Birthday / Relationship

  • Number of chlldren in care under 18 months:

  • Number of chlldren in care 18 months to 2 1/2 years:

  • Number of children in care 2 1/2 years to Kindergarten:

  • Number of children in care Kindergarten to 14 years:

  • Number of children in care 14 to 16 years:

  • CHECKLIST

  • 1. Number of children in care meets State of Kansas child care regulations

  • 2. Other employees in child care facility?

  • How many:

  • 3. Emergency numbers are listed by or on the phone

4. The following information is available for each child:

  • a. Name, address, and place of employment of parents

  • b. Health assessments for children in care

  • c. Parental permission for emergency care

5. Health certificates for:

  • a. Provider

  • b. All family members living in the home

  • c. All employees

  • 6. Dog(s), cat(s) have current rabies shot.

  • How many pets:

7. Completed plans for:

  • a. Evacuating children in case of fire.

  • b. Shelter for children in case of tornado.

8. The home:

  • a. Is safe and free of hazards

  • b. Has second exit readily available from first floor

  • c. Has fire extinguisher in the kitchen

  • d. Has medication, household poisons, sharp knives and scissors stored out of reach of children

  • e. Has gas stoves/space heaters properly vented and guarded

  • f. Has electrical outlets covered

  • g. Has approved fire inspection

  • Select date

  • 9. Meals for children in care are prepared within the facility

10. Outdoor play area:

  • a. Is fenced

  • b. Is free of hazards such as broken glass, broken toys or play equipment

  • c. Play equipment is anchored firmly in the ground (as necessary)

11. Transportation:

  • a. Transporting vehicle is covered by accident and liability insurance as required by State of Kansas Child Care Regulations

  • b. Driver is over 18 years of age with a valid driver's license

  • c. Appropriate individual restraints are used for each child transported

  • d. Parental release forms for each child

12. Water Safety - Check if Applicable

  • a. In-ground pool

  • b. Above ground pool with at least four feet above ground (steps are removed from the pool when it is not in use)

  • c. A five foot high fence separates the pool from the play area

  • d. Wading pool (water is changed daily)

  • Full Compliance

  • Violations attached

  • 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.

  • Signature of Provider:

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. Any ratings or scores displayed in our Public Library have not been verified by SafetyCulture for accuracy. Users of our platform may provide a rating or score that is incorrect or misleading. You should independently determine whether the template is suitable for your circumstances. You can use our Public Library to search based on criteria such as industry and subject matter. Search results are based on their relevance to your search and other criteria. We may feature checklists based on subject matters we think may be of interest to our customers.