When a child is admitted in a child care program a Family Child Care Admission and Arrangement Form must be signed completed and kept in the child’s record. Within this form the license holder needs to complete the liability insurance notification, permission to obtain emergency medical care and authorization to transport a child. Prior to transporting children under the age of nine the caregiver must complete the required training.
License holders must notify parents in writing if they have or do not have liability insurance prior to admission. This notification may be included on the Admission and Arrangement form. If the license holder does not have liability insurance coverage they must provide annual notice to parents on this DHS form. If the license holder has coverage and the policy changes or lapses they must provide notice to parents on this DHS form; however, if there are no changes to the continuous coverage no further notices are required.
License holders must complete the following information for all children you have cared for over the last 12 months, whether they are still in care or not and whether they are full or part time. Evaluations will be sent to at least two of these parents.
Documentation of immunizations must be in a child’s record. An immunization print out from a medical facility is a medical record and will meet the documentation requirement. It does not need a signature. If there are medical or non-medical exemptions, section 1 parts A and/or B of the immunization form will need to be completed and a signature is required. If a child has already had chickenpox and will not be vaccinated, Section 2 needs to be completed and signed.
When a child has an allergy, the parent must complete and sign the DHS approved Family Child Care Allergy Information Form. This must be completed before the child is admitted. The signed form must be in the child’s records.
As of Sept. 30, 2019 you must give this document to parents of children who enroll in your program. Parents can acknowledge receipt of this document by using the checkbox on the Admission and Arrangements form. You are not required to distribute this document to currently enrolled families, but you must make them available upon request. When an infant is present When an infant is present in a program, parents or a physician or in some situations an advanced practice registered nurse may need to complete the following forms if they apply. The signed and completed form must be in the child’s records. See Minnesota Statue 245A.1435.
Placing a swaddled infant down to sleep in a licensed setting is not recommended and is prohibited for any infant who has begun to roll over independently. However, with written consent of the parent and a one-piece sleeper equipped with an attached system that fasten securely only across the upper torso, with no constriction of the hips or legs a license holder may swaddle an infant. The DHS required form must be completed and signed in the child’s record.
When an infant is present in the program the caregiver must place the infant to sleep on its back to sleep. An infant who independently rolls onto its stomach after being placed to sleep on its back may be allowed to remain sleeping on its stomach if the infant is at least six months of age or the license holder has a signed statement from the parent indicating that the infant regularly rolls over at home. This documentation must be in a child’s record. This form may be used to fulfill this requirement.
When an infant is present the license holder must place the infant to sleep on its back unless the license holder has documentation from the infant's physician, advance practice registered nurse, or physician assistant directing an alternative sleeping position for the infant. This DHS required permission form must be completed and signed in the child’s record.
When a wading pool is used these forms are required for each child in care. The risk sheet will be given to parents and the permission form must be signed in the child’s records.
The licensed program must maintain annual documentation on cribs against the United States Consumer Product Safety Commission Web to check equipment for recalls. Monthly safety inspections on every crib, portable crib, mesh-sided or fabric-sided play yard, pack and play, or playpen used by or accessible to any child in care must be conducted and documented. This form may be used to fulfill this requirement.
The licensed program must have a written fire escape plan and a log of monthly fire and storm drills. This form may be used to fulfill this requirement.
License holders are required to complete the Certificate of Compliance of Minnesota Workers' Compensation Law form with each application (initial and renewal)
License holders must have a policy that prohibits license holders, employees, subcontractors, and volunteers, when directly responsible for persons served by the program, from abusing prescription medication or being in any manner under the influence. This policy can be contained within the license holders written policies to fulfill this requirement or this for may be used.
License holders must have a program grievance procedure for parents. This policy can be contained within the license holder's written policies to fulfill this requirement or this form may be used.
State law requires licensed family child care providers to use this form to create an emergency preparedness plan.
License holders must have emergency phone numbers of the parents and the child’s physician and dentist must be readily available. This form may be used to fulfill this requirement.
License holders do not need keep a copy in their records, however, a descriptive summary of parts 9502.0315 to 9502.0445 shall be distributed to parents.
Providers are required to maintain a log of monthly fire and storm drills. This form may be used to meet that requirement.
License holders’ policies must have written information available for discussion with parents or the agency. They must contain the following information:
This document is the paper form of the electronic checklist in ELICI that licensors use.
This document describes services that are not required to be licensed.
If you are requesting reconsideration of your correction order, you can complete this form to request it be reviewed more quickly.
This form is to document a licensed professional’s approval for an infant under one year of age to wear a helmet while sleeping in a licensed program.
This document is required when making a request for clarification of an interpretation of a licensing requirement during the annual visit.
When a fire marshal inspection is requested for a property that is not owned by the licensor holder this form must be completed.
This form is to document a parent or guardian’s request to use a cradleboard for their infant in a licensed program. This form also includes an optional checklist to use for monthly cradleboard safety checks.
Providers are required to obtain written permission to administer prescription and non-prescription medication. This form may be used to meet this requirement.
This document is optional to track the number of hours, names and dates a substitute was used to provide care.
Once the viewing of the off year video training is completed you may use this document to offer verification that you met this requirement.
From September 30, 2020, to September 30, 2021, licensors will offer technical assistance during all annual licensing inspections (re-licensing and off-year) to determine whether a provider is in compliance with the new requirements listed on this document.
This form may be used to authorize permission for the provider to transport children in a vehicle, use public transportation or participate in an activity away from childcare setting.
This is a link for the public to use to view the recall list.
Licensors are required to issue a Fix-It Ticket for certain violations identified by the Commissioner that do not imminently endanger the health, safety, or rights of children. The Fix-It Ticket provides an opportunity for the provider to correct eligible violations and avoid receiving a correction order for these violations if they are corrected within the allotted time-frame.
This document contains a list of Frequently Asked Questions (FAQ) created by the Minnesota Department of Health regarding the topic of Infant Safe Sleep.
This document is required if you will be using a substitute caregiver for more than 500 hours. This request should be made to your licensor. DHS recommends submitting variance requests no later than 30 days prior to the time you anticipate exceeding the allotted 500 hours.
Minnesota law requires licensed family child care providers, adult caregivers and substitutes to take ongoing training. As a caregiver you may want to use this form to track your ongoing training. This is not a required form.
Minnesota law requires licensed family child care providers, adult caregivers and substitutes to take initial training before caring for children and/or licensure. As a caregiver you may want to use this form to track your ongoing training. This is not a required form.