Child Care Resource and Referral
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Child Care Resource and Referral

Child Care Forms
  1. C.C.A attendance forms 470-3872 is used to track the times in and out for children who are having their child care paid for by DHS through child care assistance.
  2. C.C.A Agreement 470-3871 is the form that providers fill out prior to being approved as eligible to provide child care assistance care. It lists your rates and the rules you must abide by in order to provide care through child care assistance.
  3. Caregiver Training Tracking form is for registered child development homes to document the trainings you have attended.
  4. Consents and Releases is for any type of provider to use. Parents complete the form about who is authorized to pick up a child, what type of field trips are approved, and a photo release. This form should be kept in the child’s file at the child care program.
  5. DHS Child Care Assistance Rates is the maximum rate providers can be reimbursed for caring for children under the state subsidy program. Rates are as of 1/1/07.
  6. Emergency Contact Form is required for a registered child development home. It lists the phone numbers for fire, paramedic, poison control, and each child’s parents, doctor, and emergency contact.
  7. Emergency Plan Diagram is required for a registered child development home. You write and draw your plan in case of fire or tornado and where your outside meeting place is.
  8. Fire Fire is a form with 2 fire symbols that you must display in registered child development homes by your designated fire exits.
  9. Fire Tornado is a form with 1 symbol each for fire and tornado symbols required to be displayed in a registered child development home.
  10. Getting Started is a nineteen page document from Redleaf National Institute with information about starting a family child care business.
  11. Immunization Exemption Form is the form parents complete if they refuse to immunize their children because of religion or doctor recommendation.
  12. Immunization Certificate is the form to be completed for children by their doctor. The original or a copy is required to be on file with the child care center or registered child development home.
  13. Infant Toddler Preschool Child Health Exam Form is a form completed by the parent or guardian prior to a child enrolling and is required to be kept on file for a registered child development home.
  14. Inquiry Report Form is a form from Healthy Child Care Iowa for child care staff or registered child development home to use to document an injury or accident. One copy is to be kept in the child’s file and one copy given to the parent or guardian.
  15. Medication Record is the form to be completed by the parent and provider when an enrolled child is given any medicine, topical cream, sunscreen, diaper ointment, breathing treatment, etc. Parent signature is required.
  16. Monthly Fire Drills Smoke Alarms Tornado Drills is a form to document when provider has practiced monthly fire/tornado drills and changed batteries in smoke alarms.
  17. Physicians Statement Health Form is a form to be used by child care provider and copy kept in provider files
  18. Reg. Guidelinescomm143 Child Development Home Registration Guidelines is a 101 page document listing detailed rules and regulations concerning home registration.
  19. Reg. checklist470-0625 is the Registration Checklist that DHS or CCR&R; staff use when the do annual/renewal home visits.
  20. Rules 441-110 is a 13 page document listing guidelines for rules and regulations.
  21. School Age Health Status Forms is the packet of required information to be kept in the children’s file for each child enrolled.
Lend a Helping Hand
CCR&R of Northeast Iowa
Exceptional Persons, Inc.

P.O. Box 4090
3675 University Avenue
Waterloo, IA 50704-4090

Ph: (800) 475-0804