Free 45877.FH11 - Indiana

HEALTH CARE PROGRAM FOR CHILD CARE CENTERS
State Form 45877 (R4 / 1-07) / BCC 0054

IF THIS IS A PROPOSED (NEW SITE OR NEW OWNER) FACILITY, YOU MUST SUBMIT AN APPLICATION FOR LICENSURE PRIOR TO SUBMITTING THIS PROGRAM. Instruction for completion: Health Programs Health Program forms are to be used by Child Care Centers for the purpose of reporting the development of their written health program in compliance with the regulations for licensure. The health program must be completed in duplicate and approved prior to licensure or if there are any changes to the license that is listed under 470 IAC 3-4.7-84(c). The form incorporates the requirements of 470 IAC 3-4.7.84. All items in the forms must be carefully studied and completed by the authorities responsible for the development of the health program. A number of attachments, which are identified in the health program forms, are required. The programs will be reviewed to determine compliance with licensing requirements. Two (2) completed forms and two (2) sets of attachments (at least one form and one set of attachments must be original) shall be submitted to the Division of Family Resources, Bureau of Child Care, 402 West Washington Street, Room W386, Indianapolis, IN 46204. If the health program is not in substantial compliance with regulations, both forms and attachments will be returned to the facility for corrections and resubmittal.

STATEMENT OR EXPLANATION REGARDING HEALTH CARE CONSULTANT ACTIVITIES The health care consultant's responsibilities are to assist the Administrator or Director in developing the health policies and procedures and be available for telephone consultation as needed. The health care consultants liability is limited only to direct care and advice they may render. The rendering of direct care by the health care consultant is not required by Regulations. It is expected that all children in child care centers will continue to receive direct medical care from their family physician or clinic. If health care of children is rendered by the health care consultant, it would be an arrangement between the health care consultant and the child care facility's administration. A registered nurse approving a health program must have the following training: certification as an advance practice nurse with a maternal and/or pediatric specialty, or five (5) years documented experience in the infant and/or pediatric setting. If the First Aid Supply List or the Skin Care Procedure contains any medications, only a health care consultant with prescriptive authority (MD, DO, NP) can authorize these forms.

Over

HEALTH PROGRAM HELPS Experiences with health programs indicate the most frequent reasons for not approving submitted health programs are: 1. The lack of the health care consultants ORIGINAL signature and date on the first page. 2. The lack of the health care consultants ORIGINAL signature and date on the written first aid directives. 3. The lack of the health care consultants ORIGINAL signature and date on the first aid supply list if the list contains any type of medications (e.g. Mercurochrome, Bactine, Ointment, etc.). Your physician must indicate in writing on the list why you are to give it, how often, how much and the date and sign the list. The signature of the physician on the separate list constitutes a "written order". If first aid supplies consist of only the usual soap, water and band-aids, just indicating it in the health program is adequate. 4. A sample of the form used for the children's health examination must be submitted. The form must include all of 470 IAC 3-4.7-86 requirements. (A recommended health form is attached.) 5. A sample of the form used for employees' and volunteers' health examination must be submitted. The form must include all of 470 IAC 3-4.7-85 requirements. (A recommended health form is attached.) 6. All adults counted in the child-staff ratio must have basic first aid training within six (6) months of employment. All adults counted in the child-staff ratio for infants or toddlers must have basic first aid training prior to giving care. 7. All medications must be in a locked container and inaccessible to children. The only exceptions are those medications requiring refrigeration as indicated on the prescription label. Medications not requiring refrigeration are not to be kept in the kitchen or bathrooms. 8. There are only two (2) types of medications which may legally be given by the child care employee: those medications in a prescription container specifically ordered by a physician for the individual child, and those medications for which you have a written order from a physician for the individual child. 9. If providing care for children under two (2) years of age, two (2) Supplement Health Programs for Infant/Toddler care must also be submitted. 10.One (1) copy of each of the required forms or policies must be attached to each health program. The following have been included for your use: 1. Recommended Child Day Care Center Health Record form. 2. Recommended Adult Physician Examination Health Record form. 3. Suggested First Aid Directives (must be approved and signed by your physician). 4. Suggested Skin Care Procedures (must be completed, approved and signed by your physician). 5. Suggested First Aid Supply form 6. Medication Order form Return completed forms to: MS02 Bureau of Child Care Division of Family Resources 402 W. Washington St., Rm. W386 Indianapolis, IN 46204

HEALTH CARE PROGRAM FOR CHILD CARE CENTERS
State Form 45877 (R4 / 1-07) / BCC 0054 Date (month, day, year) Name of child care facility Location City Mailing address (if different from above) Name of Director Number of children licensed for Ages licensed for Name of Owner Hours of operation ZIP code County Telephone number (with Area Code)

(

)

From: SECTION 1 470 IAC 3-4.1-11 - HEALTH PROGRAM

To:

Definite and specific arrangements have been made for a physician to provide consultation and help maintain an adequate health program. The medical consultation will be provided by:
Name of physician (M.D. or D.O.) (print or type) Telephone number (with Area Code)

( This physician / nurse practitioner has consented to serve as the consulting health consultant.
Original Signature of Consulting Physician

)

Date signed (month, day, year)

Arrangements have been made by the facility and the consulting health consultant to establish, maintain and review the health program every two years. This health program is for a proposed facility.
Yes No

Yes Yes

No No

This facility's health program has had past approval.

The position of the person who is designated to be in charge in the absence of the director, has knowledge of all regulations and is to communicate with state personnel is: ___________________________________________.
Name of position

An agreement has been established with the hospital which is located closest to the facility for the emergency admission of a child who has a life threatening illness or injury.
Name of hospital Address of hospital (number and street, city, state, and ZIP code)

SECTION 2

470 IAC 3-4.1-12 - PRE-ADMISSION HEALTH PROCEDURES

Physician's Health Examination - Children A health examination by a physician is required for each child within three (3) months prior to admission, but no later than one (1) month after admission; and the examination includes the following: 1. 2. 3. 4. 5. Yes Yes Yes Yes Yes No No No No No Health history Physical examination and progress in development, signed by child's physician Written statement by physician or parent of immunization history Exceptions to any of the required immunizations will be permitted only with a physician's written certification. A written statement by a physician that in the opinion of the physician, the child does not have a health condition that would be hazardous either to the child or to other children in the day nursery if this child participated in the nursery's program of activities ATTACH A COPY OF THE FORM USED FOR THE CHILD'S HEALTH EXAMINATION. 6. 7. Yes Yes No There will be a written statement by the physician regarding modifications needed in the care of children who may require special attention because of medical conditions (e.g., convulsive disorders, hyperactivity, etc.) No The child will be excluded if any of the above requirements are not met
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ATTACH A COPY OF THE FORM USED FOR THE CHILD'S HEALTH EXAMINATION
Periodic Health Examination Periodic health examinations will be required as follows: 8. 9. 10. 11. Yes Yes Yes Yes No No No No Annually for children 2 years of age and younger. More frequently if the child's general condition indicates. When the child has a condition which is potentially hazardous to others. If a child frequently requires separation from the group and special observation for fatigue, illness or emotional upset, a report will be available to parents or guardians; and they will be asked to take the child to a physician for evaluation.

SECTION 3

470 IAC 3-4.1-7 (e)(2) - CHILD'S HEALTH RECORD

Health and medical records are current, on file in the licensed facility for each child and contain the following information: 12. 13. 14. Yes Yes Yes No The physician's written instructions regarding any special dietary or other special health care the child may need. No A record of all the medications and first aid given the child in the facility. No The record includes: Prescription number or name of medication, amount, time and date given, name of prescribing a. Yes No physician and person who gave the medication. Description of injury, date and time of first aid treatment and who gave the treatment. b. Yes No That parents were notified of all accidents. c. Yes No Record of absences due to illness or injury. No
470 IAC 3-4.1-8 - HEALTH EXAMINATIONS FOR PERSONS PERFORMING SERVICES

15.

Yes

SECTION 4

16. 17. 18. 19. 20.

Yes Yes Yes Yes Yes

No No No No No

Children are excluded if physical exam and immuizations are not documented within 30 days. Within 3 months prior to employment, employees shall be required to have a complete physical examination. Mantoux tuberculin skin test date and results of the test. Diagnostic chest X-ray if Mantoux test is positive. No person will be allowed to perform any services in the nursery until above is completed.

ATTACH A COPY OF THE FORM USED FOR THE EMPLOYEES' HEALTH EXAMINATION. IT MUST PROVIDE AN AREA TO RECORD RESULTS OF MANTOUX TUBERCULIN TEST HEALTH HISTORY ALLERGIES AND CHRONIC HEALTH CONDITIONS. , , 21. 22. Yes Yes No Volunteers, substitutes, student aides and any other personnel having direct contact with the children or providing food service will have the same kind of examination as the employees. No Annual Mantoux tuberculin skin tests shall be required of all adults having direct contact with children, including food service personnel.
470 IAC 3-4.1-11(a)(b) - CONTROL OF COMMUNICABLE DISEASES

SECTION 5

23. 24. 25. 26. 27. 28.

Yes Yes Yes Yes Yes Yes

No Staff members and other persons with an illness shall not be permitted to have contact with children nor be permitted to work in a capacity where illness could be transmitted. Ill staff are excluded. No Children who are ill upon arrival to the facility shall not be admitted. No Children who become ill while in attendance will be isolated, kept under direct supervision and parents notified to take the child home. No The isolation room is not used for any other purpose by children while being used as isolation quarters. No The cot(s) and other furnishings of the isolation room can be easily sanitized. oilet and lavatory facilities are located within or near the isolation room No T Where is the isolation room located? _________________________________________________________________ _______________________________________________________________________________________________

29.

Yes

No Arrangements have been made to consult the physician or the local health officer for instructions regarding control measures when exposure to a disease has occurred in the child care center. These measures include the following: Disinfection of toilet facilities, furnishings and toys or other articles used by the ill child. No a. Yes Proper disposal of body discharges. Yes No b. The cot, facilities or articles that have been used by a child suspected of having a communicable No c. Yes disease, will not be used by any other person until properly disinfected or until it is established the child did not have a communicable disease.
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SECTION 5

470 IAC 3-4.1-11(a)(b) - CONTROL OF COMMUNICABLE DISEASES (continued)

30. 31. 32. 33.

Yes Yes Yes Yes

No Arrangements have been made to notify all parents and staff members when a child is known to have a communicable disease. No Before readmission, the child care staff members will ascertain that the child does not have a condition which would prevent participation in center activities. No If pets are kept, they will be nonvicious, free from disease and shall be immunized against rabies, if indicated. No Animals will be housed in such a manner which prevents injury either to the children or the animals. Ferrets, turtles, reptiles, psittacine birds, or any wild animals will be prohibited.

SECTION 6

470 IAC 3-4.1-11(c) - CARE OF ILLNESS AND INJURY

ATTACH A COPY OF THE PHYSICIAN'S WRITTEN DIRECTIVES WHICH THE PHYSICIAN HAS SIGNED AND DATED REGARDING FIRST AID TO BE GIVEN AT THE CENTER There must be directives for the treatment of hemorrhaging, choking, seizures, poisoning, artificial respiration. (If licensed for children under 2 years of age, include directives for the treatment for shock in that age group) 34. 35. Yes Yes No First aid directives are posted in every room occupied by children. No First aid policies provide for: No All persons counted in the child/staff ratio to have training in basic first aid within three (3) a. Yes months of providing care and a refresher course every three years thereafter. (Infant and toddler staff must be trained upon employment) b. Yes No A telephone is provided within the facility and immediately available telephone numbers that include consulting physician, nearest emergency facility, ambulance service, local fire department, dentist and poison control.

It is recommended that an individual emergency card be kept for each child. The card should include the parent(s) name and telephone number, name and telephone number of a responsible person to call if the parent(s) cannot be reached as well as the child's allergies, doctor, hospital preference and a brief medical history. 36. Yes No The Red Cross First Aid Manual or its equivalent is available. a. Give title: _____________________________________________________________________________________ b. List the first aid supplies the consulting physician has indicated you are to have on hand. ______________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ c. If any medications such as aspirin, ointment, etc., are included in the first aid supplies, the consulting physician's original signature and date must be on the list, as well as why you should give the medication, how much, and how frequently. Where do you keep the supplies? __________________________________________________________________
SECTION 7 470 IAC 3-4.1-11(2)(d) - MEDICATION

37.

Yes

No The health policies include the giving or the application of medication, providing dietary supplements, making special variations in diets and carrying out special medical procedures for any child and will be done only on the written order or prescription from a physician. Individual prescriptions: a. Yes No Are kept in the original containers. b. Yes No Have the original pharmacy label showing prescription number or name of medication, date filled, physician's name, child's name and directions for use. (frequency and amount to be given)

38.

Yes

No Over-the-counter medications or physician's sample medications have a physician's written order indicating child's name, name of medication, reason for giving, frequency of use, dosage to be given. (The physician's original signature and date must appear on the written order) No All medications will be kept in a locked cabinet, drawer or box. Where is the locked cabinet, drawer or box for non-refrigerated medications located? (This location is not to be in the kitchen or bathroom) _____________________________________________________
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39.

Yes

SECTION 7

470 IAC 3-4.1-11(2)(d) - MEDICATION (continued)

40. 41. 42.

Yes Yes Yes

No Medication requiring refrigeration will be stored in a lidded, plastic container, marked "medication". No All medication given in the facility will be recorded when medication is given and by whom it is administered. No Unused portions of any child's prescription will be correctly disposed of or returned to the child's family.
470 IAC 3-4.1-11(2)(e) - PERSONAL HYGIENE

SECTION 8

43. 44. 45. 46. 47.

Yes Yes Yes Yes Yes

No The facility's schedule provides for supervised washing of hands and face before meals and after using the toilet. No Soap is provided at every handwashing sink. No Disposable towels are used and are provided in a dispenser at every handwashing sink. oilet paper is provided in a dispenser at every toilet. No T No If toothbrushes are used, they are stored separately from one another and in a sanitary manner.
470 IAC 3-4.1-11(2) - GENERAL SAFETY

SECTION 9

48. 49. 50.

Yes Yes Yes

No All equipment, materials and furnishings whether for indoor or outdoor use, are sturdy, clean and in a safe condition. No All cleaning supplies and hazardous articles are inaccessible to children. No All poisons, chemicals and items labeled "Fatal if Swallowed" are in locked storage.
470 IAC 3-4.1-15 - DISASTER SAFETY

SECTION 10

51.

Yes

No Written, posted procedures for disaster evacuations and shelter within the buildings are posted in all child care areas.

SECTION 11

470 IAC 3-4.1-14(a) - SPACE

52.

Yes

No Clothes-hanging hooks are provided for each child and are spaced far enough apart so that one child's clothing does not touch that of another child. (Hats and collars, hoods and shoulder area of coats must not touch)

SECTION 12

470 IAC 3-4.1-10(2) - PHYSICAL CARE

53. 54. 55. 56. 57.

Yes Yes Yes Yes Yes

No Supervised nap periods are provided for preschool children after the noon meal. No A firm, portable, narrow, easily-sanitized cot, whose sleeping surface is off the floor, is provided for each preschool child. No Cots are maintained in a good state of repair. No Cots are spaced two (2) feet apart on all sides. No Children lie in such a way that direct face-to-face positions are avoided. a. The majority of cots that the facility uses are: (regular canvas, vinyl, plastic, water-proofed canvas) _____________________________________________________________________________________________ b. The majority are sanitized by the following method: ____________________________________________________ _____________________________________________________________________________________________ (Regular canvas coverings are taken off the frame and washed in bleach and warm water in a clothes washer for 25 minutes.)

58. 59.

Yes Yes

No A different child uses a different cot each day. No The same child uses the same cot each day. a. How frequently are cots sanitized? _________________________________________________________________ Each child's blanket is stored: No On individually marked cot b. Yes No In individually marked cubicle c. Yes No In individually marked sack d. Yes
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SECTION 13

470 IAC 3-4.1-7(d) - SMOKING

60.

Yes

No Smoking is prohibited in the kitchen, in the presence of children and in areas which will be occupied by children.

SECTION 14

470 IAC 3-4.1-9-2(c) - TWO YEAR OLDS WHO ARE NOT TOILET TRAINED

61.

Yes

No We accept two year old children who are in diapers. The diaper changing table consists of: Soft washable (plastic covered) pad a. Yes No A sanitizable table b. Yes No Clean waterproof, disposable paper which covers the entire pad and is discarded after each use. c. Yes No No The diaper changing pad is sanitized when it becomes soiled and at the end of the day. No Time of bowel movements is entered on a daily chart. No The consulting physician has approved a skin cleansing procedure. ATTACH A COPY OF THE SKIN CLEANSING PROCEDURE THAT CONTAINS THE HEALTH CARE CONSULTANTS ORIGINAL SIGNATURE AND DATE

62. 63. 64.

Yes Yes Yes

65. 66. 67.

Yes Yes Yes

No Caregivers wash their hands before and after diapering children. No Soiled diapers shall be kept in a plastic bag in a tightly covered, sanitary container that is inaccessible to children. No A supply of diapers shall be available at all times, stored off the floor, and inaccessible to children.

HAVE YOU ATTACHED ONE (1) COPY OF THE FOLLOWING TO EACH PROGRAM? The form used for the child's health examination. The first aid directives for the care of ill or injured children that have been signed and dated by the supervising physician. These procedures must itemize the care for seizures, choking, hemorrhage, poisoning and artificial respiration (and shock if licensed for children under 2 years of age). The form used for the employee health examination. Health care consultants signed and dated skin cleansing procedures for diapered 2 year olds.
Signature of: (check one) Owner President of Board of Directors Director Date signed (month, day, year)

Page 5

HEALTH CARE PROGRAM FOR CHILD CARE CENTERS PROCEDURE FOR SKIN CARE - DIAPERING
State Form 49971 (R / 11-06) / BCC 0021

BUREAU OF CHILD CARE DIVISION OF FAMILY RESOURCES

Objective:

T cleanse baby's skin after urination and / or bowel movement. o To insure comfort to baby. To prevent diaper rash.

Equipment:

Waterproof paper (wax paper) * ________________________________ Soap for cleaning after bowel movement Paper towel for drying only Diaper Tightly covered sanitary waste containers, lined with plastic (one for soiled diapers and one for washcloths). Disposable gloves Sanitizing solution (1% bleach solution or its equivalent).

Procedure:

1. 2. 3. 4. 5. 6. 7. 8. 9.

Wash hands with soap and warm water and dry with disposable paper towel. Gather equipment and put on diapering area. Spread wax paper on changing table. Cover entire length and width of pad. Pick up baby and place on diapering table. Put on gloves (if blood is present, medical disposable gloves must be worn.) Release diaper. Using ankle hold to insure safety, remove soiled diaper. Place soiled diaper on wax paper or into plastic bag. Gently wash baby's bottom with * ________________________________ downward cleansing, and dry with towel. Avoid hard rubbing. Baby's skin is very sensitive. T cleanse girls, spread labia apart gently, wash and dry between skin folds (cleaning downward only o - cleaning cloth must not touch vaginal area if it has touched rectal area). T cleanse boys, merely wash and dry. In uncircumcised boy, never attempt to pull back the foreskin. o Use soap and rinse well if child had bowel movement.

10. Remove gloves. 11. Put diaper on child. 12. Wash childs hands. 13. Take child to safe area. 14. If blood is present on diaper table, put medical gloves on. 15. Discard soiled diaper, washcloth and towel, and wax paper into tightly covered sanitary waste container lined with plastic bag. 16. Sanitize diaper changing pad and table if soiled after a diaper change or at least daily. 17. Remove gloves and discard in covered container. 18.

Wash hands with soap and warm water and dry with disposable paper towel.

19. Record on child's record and note any unusual observations such as rash, loose bowel movement, bleeding, etc. * State what you will use for skin cleansing (i.e., disposable wipe, terry washcloth, etc.).
Signature of physician / nurse practitioner Date signed (month, day, year)

HEALTH CARE PROGRAM FOR CHILD CARE CENTERS CHILD CARE CENTER HEALTH RECORD
State Form 49969 (R2 / 11-06) / BCC 0019

BUREAU OF CHILD CARE DIVISION OF FAMILY RESOURCES

Name of child (last, first) Address (number and street, city, state, and ZIP code) Child lives with (relationship) Name

Date of birth (month, day, year)

Date of admission (month, day, year)

(
MEDICAL HISTORY

T elephone number

)

Communicable Disease Measles Rubella (German Measles) Chickenpox Mumps Scarlet Fever Whooping Cough Other: _______________

Month / Year Allergies:

Condition

Explain if present

Handicapping conditions: Other:

PHYSICAL EXAMINATION
Date of exam (month, day, year) Age of child

Skin Lymphnodes Eyes Ears Nasopharynx Teeth and Mouth
Note any unusual findings:

Heart Lungs Abdomen Genitalia Skeleton Other:

Does this child have any health condition that would be hazardous either to the child or to other children in a group setting as a result of participation in normal activities (including sports)? If Yes, what modification of normal activities would be necessary to protect the child and the child's classmates:

Yes

No

Have you prescribed any medications or special routines which should be included in the center's plans for this child's activities? Explain:

Yes

No

(Over)

HISTORY OF IMMUNIZATIONS AND TEST (indicate month / day / year) 1 DTaP / DT 2 3 4 5

1 Hib

2

3

4

1 IPV (Polio)

2

3

4

5

1

2

3

4

5

*

Influenza (Flu)

1 Measles Mumps Rubella (MMR) 1 Rotavirus (RGE)

2

2

3

1 Varicella (Varivax) 1 Pneumococcal (PCV) (Prevnar) 1 HEPA

2 or Chicken Pox Disease

Month / year

2

3

4

2

1 HBV (HEP B)

2

3

* Recommended yearly.
Name of physician / nurse practitioner completing form (please print) Signature of physician / nurse practitioner

(

T elephone number

)

ADDITIONAL NOTES AND INSTRUCTIONS

HEALTH CARE PROGRAM FOR CHILD CARE CENTERS RECORD OF ADULT PHYSICAL HEALTH EXAMINATION
State Form 49970 (R / 11-06) / BCC 0020

BUREAU OF CHILD CARE DIVISION OF FAMILY RESOURCES

Name Address (number and street, city, state, and ZIP code)

Date of birth (month, day, year)

MEDICAL HISTORY I. List past hospitalizations / operations / accidents:

II. Communicable diseases you have had: Measles Chicken Pox Other: III. Conditions (Please explain if present):
Allergies: Chronic health conditions: Use of any drugs / medication: Why? Month / year Month / year

Scarlet Fever Mumps

Month / year Month / year

Rubella (German Measles) Whooping Cough

Month / year Month / year Month / year

PHYSICAL EXAMINATION I. Mantoux TB skin test * Chest X-ray, if above skin test is positive? Other laboratory test as ordered by physician: II. Does this person have any health condition that would be hazardous to the person or to the children in a group setting as a result of participation in normal activities (including sports)? No Yes If Yes, what modifications of normal activities are necessary? III. Have you prescribed any medications and / or special routines (such as diet) which should be included in planning this person's activities? No
Explain: Date (month, day, year) Date (month, day, year) Result (in mm) Result

Yes

Date of exam (month, day, year)

Signature of physician / nurse practitioner

* Annual testing for tuberculosis is required.

HEALTH CARE PROGRAM FOR CHILD CARE CENTERS SUGGESTED FIRST AID DIRECTIVES
Part of State Form 45877 (R4 / 1-07) / BCC 0054

BUREAU OF CHILD CARE DIVISION OF FAMILY RESOURCES

CHOKING (Conscious, ages 1 and above) - Stand or kneel behind child with your arms around his waist and make a fist. Place thumb side of fist in the middle of abdomen just above the navel. With moderate pressure, use your other hand to press fist into child's abdomen with five (5) quick, upward thrusts. Keep your elbows out and away from child. Repeat thrusts until obstruction is cleared or child begins to cough or becomes unconscious. (Unconscious) - Contact 911 and/or emergency services immediately and begin CPR. (Conscious Infants) - Have someone call 911 or, if you are alone, call 911 as soon as possible. Support infant's head and neck. Turn infant face down on your forearm. Lower your forearm onto your thigh. Give five (5) back blows forcefully between infant's shoulder blades with heel of hand. Turn infant onto back. Place middle and index fingers on breastbone between nipple line and end of breastbone. Quickly give at least five (5) chest thrusts by compressing the breastbone one-half to one inch with each thrust. Repeat backblows and chest thrusts until object is coughed up, infant starts to cry, cough, and breathe, or medical personnel arrives and takes over. (Unconscious Infants) - Contact 911 and/or emergency services immediately and begin CPR. POISONING Call Poison Control Center (1-800-222-1222) immediately! Have the poison container handy for reference when talking to the center. Do not induce vomiting or give anything by mouth. Check the child's airway, breathing and circulation. HEMORRHAGING Use a protective barrier between you and the child (gloves). Then, with a clean pad, apply firm continuous pressure to the bleeding site. Do not move or change pads, but you may place additional pads on top of the original one. If bleeding persists, call a doctor or an ambulance. Open wounds may require a tetanus shot. SEIZURE Clear the area around the child of hard or sharp objects. Loosen tight clothing around the neck. Do not restrain the child. Do not force fingers or objects into the child's mouth. After the seizure is over and if the child is not experiencing breathing difficulties, lay him on his side until he regains consciousness or until he can be seen by emergency medical personnel. After the seizure, allow the child to rest. Notify parents immediately. If child is experiencing breathing difficulty, or if seizure is lasting longer than 5 minutes, call an ambulance at once. ARTIFICIAL RESPIRATION (Rescue Breathing) Position child on the back; if not breathing, open airway by gently tilting the head back and lifting chin. Look, listen, and feel for breathing. If still not breathing, keep head tilted back and pinch nose shut. Give two regular breaths, and then one regular breath every 4 seconds thereafter. Continue for one minute; then look, listen, and feel for the return of breathing. Continue rescue breathing until medical help arrives or breathing resumes. * If using one-way pulmonary resuscitation device, be sure your mouth and child's mouth are sealed around the device.

(Modification for infants only) - Proceed as above, but place your mouth over nose and mouth of the infant. Give light puffs every 3 seconds. SHOCK If skin is cold and clammy, as well as face pale or child has nausea or vomiting, or shallow breathing, call for emergency help. Keep the child lying down. Elevate the feet if there are no leg injuries or pain.

Signature of consulting physician

Date signed (month, day year)

FIRST AID SUPPLY LIST
INSTRUCTIONS:

Part of State Form 45877 (R4 / 1-07) / BCC 0054

BUREAU OF CHILD CARE DIVISION OF FAMILY RESOURCES

Post with stored medication and supplies.

Mild soap Adhesive bandages Gauze pads and tape Medical gloves 1% bleach One-way pulmonary resuscitation device (artificial respiration mask) (Keep in locked cabinet) Alcohol Hydrogen Peroxide Thermometer Scissors Flashlight Medications, ointments only as follows: (include name of medicine or skin product, dosage, frequency of use and reason to use for each item listed.) *

EXAMPLE 1. 2. Tylenol (acetaminophen) - give as directed on bottle every four (4) hours for fever 101 F or higher or for pain. Robitussin - for cough

(Give according to directions on bottle.)

* If no medication or ointments are included, form does not need to be signed.
Signature of physician / nurse practitioner Date (month, day, year)

RECORD OF MEDICATION ORDER
State Form 49968 (R / 12-06) / BCC 0018

BUREAU OF CHILD CARE DIVISION OF FAMILY RESOURCES

All medications, medicinal products, physicians sample medications, and medicinal skin care products given or used at a child care center must include the exact name of medication, dosage to be given, time to be given and reason for use. (If used for fever, the degree of temperature must be stated.) A physicians order is valid for one year.
1. Name of child Dosage to be given Reason for use: Exact name of medication Time to be given (frequency)

Signature of physician / nurse practitioner 2. Name of child Dosage to be given Reason for use: Exact name of medication Time to be given (frequency)

Date (month, day, year)

Signature of physician / nurse practitioner 3. Name of child Dosage to be given Reason for use: Exact name of medication Time to be given (frequency)

Date (month, day, year)

Signature of physician / nurse practitioner 4. Name of child Dosage to be given Reason for use: Exact name of medication Time to be given (frequency)

Date (month, day, year)

Signature of physician / nurse practitioner 5. Name of child Dosage to be given Reason for use: Exact name of medication Time to be given (frequency)

Date (month, day, year)

Signature of physician / nurse practitioner

Date (month, day, year)