Forms for Child Care

Background Studies

• Background Study Documentation Form-72000-113 8/10 (PDF)

Class Worksheets

• Class A License Worksheet-72000-129 A 9/14 (PDF)
• Class C-1 License Worksheet-72000-129 C-1 9/14 (PDF)
• Class C-2 License Worksheet-72000-129 C-2 9/14 (PDF)
• Class C-3 License Worksheet-72000-129 C-3 9/14 (PDF)

Emergency/Safety

• Child Care Emergency Plan-DHS-7955 (PDF)
• Fire Extinguisher List-72000-7 3/22 (PDF) (must be tagged annually)
• Guidance:  Poisonous Plants in Family Child Care-DHS-7745 (PDF)
• Monthly Crib Safety Inspection Form-DHS-7743 (PDF)
• Monthly Drill Log - Child Care Homes-72000-63 11/19 (PDF)
• Serious Injury Reporting Form - Family Child Care-DHS-7774 (PDF)

Miscellaneous

• Certificate of Compliance-MN Workers’ Compensation (PDF)
• Child Care Assistance Provider Form-EA-572 6/15 (PDF)
• Child Enrollment-Family Child Care-DHS-7934 (PDF)
• Electronic Data Consent-70000-21 9/20 (PDF)
• Family Child Care Request for Expedited Correction Order Reconsideration-DHS-TCM-1053-327240 (PDF)
• Family Child Care Weekly Attendance Schedule-DHS-7297A (PDF)
• Licensing Requirement Dispute - Family Child Care-DHS-7966 (PDF)
• Physician’s Report-DHS-1995 (PDF)
• Provider Training Record-CC-72000-27 4/21 (PDF)
• Substitute Tracking-Child Care Licensing-72000-153 11/19 (PDF)

Variances

• Variance Request-Family Child Care-DHS-7297 (PDF)
• Variance Request Form - Extended Use of Substitutes - Family Child Care-DHS-7964 (PDF)
• Variance Request-Notice for Parents-DHS-7297B (PDF)
• Weekly Attendance Schedule-FCC-DHS-7297A (PDF)

Miscellaneous

• Child Care Provider's Policies and Contract-SAMPLE (PDF)
• Family Child Care Admission and Arrangements Form-DHS-7776 (PDF)
• Family Child Care Allergy Information Form-DHS-7736 (PDF)
• Immunization Form-MDH (PDF)
• Liability Insurance Notice to Parents or Guardians-DHS-7741 (PDF)
• Maltreatment of Minors Mandated Reporting Form-DHS-7634C (PDF)
• Permission to Administer Medication-72000-8 3/13 (PDF)
• Permission to Administer Non-Prescription Products-72000-9 3/13 (PDF)
• Rule and Statute Summary - Family Child Care-DHS-7747 (PDF)
• Travel and Activity Authorization-72000-57 8/11/10 (PDF)

Pools

• Swimming Pool Permission Form-DHS-7749A (PDF)
• Swimming Pool Risks-DHS-7749B (PDF)
• Wading Pool Permission Form-DHS-7749C (PDF)
• Wading Pool Risks-DHS-7749D (PDF)

Safe Infant Sleep

• Infant Rolling Over Parent Statement for Infant Less Than Six Months Old-DHS-7219 (PDF)
• Physician Directive for Alternative Infant Sleep Position-DHS-7216 (PDF)
• Swaddling Consent for an Infant-DHS-7218 (PDF)