Forms and Resources for Family Child Care Homes

Forms and documents

Become a licensed provider

• Initial License Application (Spanish)
• Adult Medical Statement

Change or update your license

• Notify Licensing About Changes to Your Program (online form)
  • This form is required for any changes that affect the services you provide including change of address that differ from what’s stated in your license or application

Inspection Forms

• Inspection Form (Sample)
• Corrective Action Plan and Resolving Disputed Violations (Spanish)
• Guide to the Child Care and Youth Camp Investigation Process

Children’s Records

• Child Enrollment Packet (English) (Spanish)
• Child Enrollment Form (English) (Spanish)
• Early Childhood Health Assessment Record (Birth to Age 5)
• Emergency Phone Numbers (English) (Spanish)
• Health Assessment Record (School Age)
• Immunization Requirements Schedule
• Incident Log (English) (Spanish)
• Medical Exemption Certificate
• Written Permission Form (English) (Spanish)
• Sample forms
  • Child Records Checklist (English) (Spanish)

Record keeping

• Child Developmental Milestones(English) (Spanish)
• Sample forms
  • Emergency Plan (Sample) (Spanish)
  • Household Member Records Checklist (Spanish)

First Aid, CPR and Medication Administration

• Authorization for Administration of Medication (Spanish)
• First Aid & CPR Courses for Child Care (Spanish)
• Individual Plans of Care in Child Care
• Parent Authorization for Administration of Non-Prescription Topical Medications (Spanish)
• Petition for Special Medication Authorization
• Potassium Iodide (KI) Authorization Form and Fact Sheet (Spanish)
• Sample Forms:
  • Written Approval for Administration of Medication Training Certificate
  • Individual Plan of Care(English)(Spanish)
  • Medication Administration Record (MAR)
  • Medication Administration Sample Policy (Spanish)

Mandated reporting

• DCF mandated reporter online reporting portal
• DCF 136 Form – report of suspected child abuse or neglect
• OEC Family Child Care Self Report (online form)

Technical assistance and support

• Request technical assistance (online form)
• DCF mandated reporter training
• Family Child Care Capacity Q & A (Spanish)
• Checklist for Maintaining Regulatory Compliance (Spanish)
• Complying with the ADA
• CT Staffed Family Child Care Networks
• Guidance to Licensed FCCH Providers-Use of Approved Substitutes (English) (Spanish)

Health and safety resources

• Green Cleaning in Child Care Settings
• Hand Sanitizer Fact Sheet (Spanish)
• How to Request an Immunization Record From CIRTS
• Integrated Pest Management for Child Care Facilities
• Managing Asthma in Child Care Facilities
• MRSA Fact Sheet
• Child and Adult Care Food Program (CACFP) (Spanish)
• Protecting Children and Staff on Hot Weather Days
• Sleep Arrangements for Infants (English) (Spanish)

For information and resources concerning congenital cytomegalovirus, lead, bed bugs, and other related topics, please visit the CT Department of Public Health (DPH).

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