Documents, Forms, and Policies
These documents, sample forms, and sample policies can be adapted to meet the needs local child care facilities. Items marked [DOC] will download as a Microsoft Word document, items marked [PDF] open in a new tab. Contact a local Child Care Health Consultant for guidance using these documents.
*Policies that are required by NC Child Care Rules.
Children’s Medical Report [PDF]| Reporte Medico para Niños [PDF]
Emergency Drill Log Centers [PDF]
Emergency Drill Log FCCH [PDF]
Children’s Environmental Health
Vomit and Diarrhea Clean Up Plan and Poster for Child Cares
Hazardous Item Storage
Hazardous Item Storage [PDF] | Almacenamiento de artículos peligrosos para guarderías [PDF]
Tobacco Free
Tobacco Free Child Care Center Policy Sample [DOC] | Normas de prohibición total de consumo de productos del tabaco en establecimientos de cuidado infantil Muestra [DOC]
Tobacco Free Child Care Family Child Care Home Policy Sample [DOC] | Normas de prohibición total de consumo de productos del tabaco en hogar de cuidado infantil familiar de cuidado infantil Muestra [DOC]
Tobacco free poster [PDF] | Libre de Tobaco [PDF]
Policies
NC Child Care Immunization Policy Sample [DOC]
Communicable Disease and Exclusion Policy Sample – added February 2024 [DOC]
Forms
Child Immunization History [PDF]
Inclusion/Exclusion Notification for Parents – updated February 2024 [DOC]
One Wipe Per Swipe Flyer for Parents – updated June 2024 [DOC]
Sample notification of exposure to communicable disease [DOC] – See Communicable Diseases and Exclusion from Child Care chart [HTML].
Medical Action Plans | Planes de Acción Médica
Medical Action Plan: General [PDF] | Plan de Acción Médico del Niño [PDF]
Allergy and Anaphylaxis Emergency Plan (non-food) [PDF]
Food Allergy and Anaphylaxis Emergency Care Plan [PDF] | Plan de Atención de Emergencias de Alergias Alimentarias y Anafilaxia [PDF]
Child Care Diabetes Medical Management Plan [PDF]
Medical Action Plan: Asthma [PDF] | Plan de Acción Médico: Asma [PDF]
Seizure Action Plan [PDF] | Plan de Acción para Crisis Epilépticas [PDF]
Medication Administration Forms | Formularios de Administración de Medicamentos
Medication Error Report [PDF] | Informe de Errores con Medicamentos [PDF]
Medication Administration Permission and Record [PDF] | Formulario de Permiso para la Administración de Medicamentos [PDF]
Medication Administration Permission – topical ointments [PDF] | Formulario de Autorización para la Administración de Medicamentos de Uso Tópico sin Receta [PDF]
Policy
NC Medication Administration Policy Sample [DOC]
Note: Before implementing a medication administration policy or using these forms, contact a local CCHC for training and technical assistance.
Family Provided Milk Substitution Permission Form Sample [DOC] – updated 11/29/2023
Safe Sleep*
Infant Toddler Safe Sleep Policy Sample [DOC] | Normas de seguridad del sueño de bebés y niños pequeños Muestra [DOC]
Alternative Sleep Position Health Care Professional Waiver [PDF] | Autorización ITS-SIDS de profesionales médicos Posturas alternativas para dormir/uso de cuñas [PDF]
Alternative Sleep Position Parent Waiver [PDF] | Autorización ITS-SIDS de los padres Posturas alternativas para dormir [PDF]
Sample Sleep Chart [PDF]
For additional policies: Model Child Care Health Policies 5th Edition published by the Academy of Pediatrics in October 2013.