Documents, Forms, and Policies
These documents, sample forms, and sample policies can be adapted to meet the needs of 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.
Documents and Forms
- 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]
- Child Immunization History [PDF]
- Children’s Medical Report [PDF]
- Reporte medico para niños [PDF]
- Notification of Facility Working with a Child Care Health Consultant [DOC] | [PDF]
- Emergency Drill Log Centers [PDF]
- Emergency Drill Log FCCH [PDF]
- Family Provided Milk Substitution Permission Form Sample [DOC] | [PDF]
- Hazardous Item Storage [PDF]
- Almacenamiento de artículos peligrosos para guarderías [PDF]
- Inclusion/Exclusion Notification for Parents [DOC] | [PDF]
- Medical Action Plans
- Allergy and Anaphylaxis Emergency Plan [PDF]
- Plan de emergencia para alergias y anafilaxia [PDF]
- For food allergies, see the Food Allergy and Anaphylaxis Emergency Care Plan below
- Asthma [PDF]
- Plan de acción médico: asma [PDF]
- Child Care Diabetes Medical Management Plan [PDF]
- Food Allergy and Anaphylaxis Emergency Care Plan [PDF]
- Plan de atención de emergencias de alergias alimentarias y anafilaxia [PDF]
- General [PDF]
- Plan de acción médico del Niño [PDF]
- Seizure Action Plan [PDF]
- Plan de acción para crisis epilépticas [PDF]
- Allergy and Anaphylaxis Emergency Plan [PDF]
- Medical Waiver Sign [PPT] | [PDF]
- Medication Administration Permission – topical ointments [PDF]
- Formulario de autorización para la administración de medicamentos de uso tópico sin receta [PDF]
- Medication Administration Permission and Record [PDF]
- Formulario de permiso para la administración de medicamentos [PDF]
- Medication Error Report [PDF]
- Informe de errores con medicamentos [PDF]
- One Wipe Per Swipe Flyer for Parents [PPT] | [PDF]
- Sample Notification of Exposure to Communicable Disease [DOC] | [PDF] – See Communicable Diseases and Exclusion from Child Care Chart [HTML]
- Sample Sleep Chart [DOC] | [PDF]
- Staff Health Assessment/Medical Report [PDF]
- Tobacco free poster [PDF]
- Libre de tobaco [PDF]
- Tuberculosis Screening or Test Record [PDF]
- Formulario de detección de tuberculosis [PDF]
- Vomit and Diarrhea Clean Up Plan and Poster for Child Cares [HTML]
Sample Policies
Sample policies are intended for early care and education programs to download and adapt to their needs.
*Policies that are required by NC Child Care Rules.
- Biting [DOC] | [PDF]
- Child Care Toothbrushing [DOC] | [PDF]
- Child Immunization [DOC] | [PDF]
- Communicable Disease and Exclusion [DOC] | [PDF]
- Confidentiality [DOC] | [PDF]
- Infant Toddler Safe Sleep* [DOC] | [PDF]
- Medication Administration [DOC] | [PDF]
- Shaken Baby Abusive Head Trauma* [DOC] | [PDF]
- Tobacco Free Child Care Center [DOC] | [PDF]
- Tobacco Free Child Care Family Child Care Home [DOC] | [PDF]
- Tummy Time [DOC] | [PDF]
Note: Before implementing a medication administration policy or using the medication administration forms, contact a CCHC for training and technical assistance.
For additional policies: Model Child Care Health Policies 5th Edition published by the Academy of Pediatrics in October 2013.