City of Mission, KS Safety Evaluation Form

• Conducted on

  Date

• Prepared by

• Type of Facility

  Day Care Home

  Group Day Care Home

  Child Care Center

• Name of Applicant:

• Date of Survey:

  Date

• 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

  Yes

  No

  N/A

• 2. Other employees in child care facility?

  Yes

  No

  N/A

• How many:

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

  Yes

  No

  N/A

4. The following information is available for each child:

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

  Yes

  No

  N/A

• b. Health assessments for children in care

  Yes

  No

  N/A

• c. Parental permission for emergency care

  Yes

  No

  N/A

5. Health certificates for:

• a. Provider

  Yes

  No

  N/A

• b. All family members living in the home

  Yes

  No

  N/A

• c. All employees

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• How many pets:

7. Completed plans for:

• a. Evacuating children in case of fire.

  Yes

  No

  N/A

• b. Shelter for children in case of tornado.

  Yes

  No

  N/A

8. The home:

• a. Is safe and free of hazards

  Yes

  No

  N/A

• b. Has second exit readily available from first floor

  Yes

  No

  N/A

• c. Has fire extinguisher in the kitchen

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• f. Has electrical outlets covered

  Yes

  No

  N/A

• g. Has approved fire inspection

  Yes

  No

  N/A

• Select date

  Date

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

  Yes

  No

  N/A

10. Outdoor play area:

• a. Is fenced

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

11. Transportation:

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• d. Parental release forms for each child

  Yes

  No

  N/A

12. Water Safety - Check if Applicable

• a. In-ground pool

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• d. Wading pool (water is changed daily)

  Yes

  No

  N/A

• 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:

  Sign