Educator Home Visit Record

• Conducted on

  Date

• Prepared by

• Location
  Address

• Educator

• TRIM file number

SITE INFORMATION

• Date:

  Date

• Educator

• Weather:

  Select Hot Cold Wet/ raining Cloudy Warm

  • Hot
  • Cold
  • Wet/ raining
  • Cloudy
  • Warm
• Address:
  Address

• Front door locked

• Visitor's book signed

• Sleep log checked

• Sleeping children sighted

  N/A

  Yes

  No

• Accessible areas sighted

• Inaccessible areas sighted

• Environmental checks

• Pets inaccessible to children

  N/A

  Yes

  No

• Pet food / water / bedding inaccessible to children

  N/A

  Yes

  No

• Comments

ON ARRIVAL

• What are the children involved in?

• Add media

  Media

• Television

  On

  Off

• Music

  On

  Off

CHILDREN IN CARE

• Child 1.

• Child 2.

• Child 3.

• Child 4.

• Child 5.

• Absent:

• Other people present:

PROGRAM / PLANNING

• Up to date:

• Displayed:

• Sighted:

• Add media

  Media

• Comments

NUTRITION

• Menu displayed:

• Sighted:

• Was water accessible to children:

• Add media

  Media

• Comments:

GENERAL COMMENTS

• Add media

  Media

• Educator Goals:

• Follow-up required by Educator:

• CDC Follow - up:

• Educator's Signature

  Sign

• CDC's Signature

  Sign