Free 45878.FH11 - Indiana

SUPPLEMENT TO HEALTH PROGRAM FORM INFANT - TODDLER
State Form 45878 (R3 / 1-07) / BCC 0055

IF THIS IS A PROPOSED (NEW SITE OR NEW OWNER) FACILITY, YOU MUST SUBMIT AN APPLICATION FOR LICENSURE PRIOR TO SUBMITTING THIS PROGRAM.

Instructions for completion: Supplemental Health Program forms are to be used by Child Care Centers with children of ages from six weeks to two years (Infant-Toddler) for the purpose of reporting the development of their written health program in compliance with regulations for licensure. 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 health program will be reviewed to determine compliance with the licensing requirements of 470 IAC 3-4.7. You must send one (1) original program, one (1) original set of attachments and one (1) copy of the program with one (1) copy of the attachments to the Division of Family Resources, Bureau of Child Care, 402 West Washington St., 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 child care center for corrections and resubmittal. The following forms have been included for your use: 1. Recommended Handwashing Procedure 2. Weekly Record of Daily Needs 3. Suggested Feeding Plan 4. Procedure For Skin Care - Diapering Return the two (2) programs and two (2) sets of attachments to: MS02 Bureau of Child Care Division of Family Resources 302 W. Washington St., Room W386 Indianapolis, IN 46204

SUPPLEMENTAL HEALTH PROGRAM FOR CHILD CARE CENTERS PROVIDING INFANT-TODDLER CARE
State Form 45878 (R3 / 1-07) / BCC 0055

Date (month, day, year) Name of child care center Location City Mailing address (if different from above - number and street, city, state, and ZIP code) Name of director Number of infants licensed for Name of owner Number of toddlers licensed for ZIP code County Telephone number (with Area Code)

(

)

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:
Original Signature of consulting physician / nurse practitioner Date signed (month, day, year)

470 IAC 3-4.2-6 PROGRAM OF INFANT-TODDLER CARE
1. Yes No In order to assure consistency of care in the child's home and the center, a program of care for each child is planned

and written prior to his admission by the director or person in charge of the infant-toddler section in cooperation with the experienced child care worker and the child's parent.
Yes Yes No No

Daily activities for infants and toddlers will provide for: When awake, infants shall be out of their cribs and engaged in appropriate activity. Toddlers shall be taken out of doors daily when weather permits. No A chart for recording daily information on each child is posted in a conspicuous place in each infant and toddler room. Yes No This chart is kept for at least one month. The type of information recorded on the chart for each child should include the following: Yes No a. Medication given Yes No b. Time and amount of food and fluid intake Yes No c. If still hungry or refusing feeding Yes No d. Urine and bowel movements Yes No e. Vomiting, diarrhea, constipation Yes No f. Sleep/nap record Yes No g. Nose bleeds, injuries Yes No h. Mood of child Yes No i. Skin condition, elevated temperature Yes No j. Awake activities
a. b.

2.

Yes

ATTACH A COPY OF THE FORM USED TO RECORD THE DAILY NEEDS CHART
3. Yes No

Parents shall be informed of any important information regarding their child on the day of occurrence.
PHYSICAL CARE

4. 5. 6.

Yes Yes Yes

No All soiled bedding and terry cloth washcloths are laundered for 25 minutes in 160o F water. No Handwashing procedures are posted. All child care personnel wash their hands before and after giving feedings,

bathing, diapering or changing clothing for infants and toddlers.

No Caregivers' outer garment coverings shall be changed when soiled.

ATTACH A COPY OF THE HANDWASHING PROCEDURES

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PHYSICAL CARE (continued) 7. Yes No An adult caretaker shall be present in an infant or toddler room at all times and child-staff ratios shall be maintained. Yes No a. Even if all infants are asleep. No Bed clothing will be changed immediately when wet or soiled, otherwise once a day. No A changing table shall include a soft, washable, plastic-covered pad on the sanitizable table and a clean strip of

8. 9.

Yes Yes

disposable, waterproof paper shall be used to cover the entire pad.
Yes Yes No No

a. b. 10. Yes

The pad is sanitized when it is soiled or at least daily. A fresh, clean strip of waterproof, disposable paper shall be placed over the entire pad after each change.

No The consulting physician has specified procedures on how to cleanse the child's skin.

ATTACH A COPY OF THE SKIN CARE PROCEDURES THAT CONTAIN THE HEALTH CARE CONSULTANTS ORIGINAL SIGNATURE AND DATE
a. b. c. d. e. f. g. Yes Yes Yes Yes Yes Yes Yes No No No No No No No

These are posted by the changing table and easily seen in each infant/toddler room. Disposable medical gloves are worn if blood is present. Gloves are to be removed after the skin is cleansed and before the clean diaper is tabbed/pinned. Soiled diapers are placed in a tightly covered container in a plastic bag, tied tightly and removed from the center at the close of each day. Cloth diapers laundered by a laundry service or furnished by parents will be kept separate from the other diapers and linens. Clean diapers are stored in an area inaccessible to children and off the floor. Clean clothing and soiled clothing are kept in separate, closed containers.

470 IAC 3-4.2-7 - HEALTH REQUIREMENTS 11. 12. 13. Yes Yes Yes No Arrangements have been made for each infant and toddler to have a written statement from a physician which

includes current information on immunization status and health examination.

No A current feeding plan is available for each infant. No The child shall be excluded if the health requirements are not met.

ATTACH A COPY OF THE FORM USED FOR THE FORMULA/FOOD PLAN
470 IAC 3-4.2-5 - ACCIDENTS AND SUDDEN ILLNESS 14. 15. Yes Yes No All staff members who have direct contact with infants and toddlers shall have current first aid training and current

knowledge of the treatment for choking, seizure, hemorrhaging, poisoning, artificial respiration and shock. prior to giving care.

No All staff members who have direct contact with infants and toddlers shall have current training in first aid procedures

470 IAC 3-4.2-9 - EQUIPMENT 16. 17. 18. 19. 20. 21. 22. 23. Yes Yes Yes Yes Yes Yes Yes Yes

There will be at least 3 feet between all cribs and cots. Only children under 30 inches tall shall use a portacrib (see definition of portacrib). Only children who are under 35 inches tall shall use a full size crib (see definition of a full size crib). Crib mattresses are firm and securely covered with waterproof material not dangerous to children. Mesh cribs, play pens and bassinets of any type are prohibited for sleeping. Yes No All surfaces are easily sanitized. No Diaper bags brought from home are prohibited in the children's room. No All areas, surfaces and items with which infants and toddlers will come in contact will be clean and easily sanitized. No All articles which the infant or toddler is given to handle are nontoxic, washable, too large to swallow, without rough edges or sharp corners and sanitized on a regular basis.
No No No No No

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470 IAC 3-4.2-9 - EQUIPMENT (continued) 24. 25. Yes Yes No There is a rocking chair in the infant room for each caregiver. No Floors are cleaned/vacuumed daily when children are not present and shampooed as frequently as necessary to

keep it clean.

THE ABOVE INFORMATION AND ATTACHMENTS ARE CORRECT, ACCURATE AND SERVE AS A WRITTEN COMMITMENT TO FOLLOW CONTENT AND PRACTICES REFERRED TO WITHIN.
Signature of: (check one) Owner President of Board of Directors Director Date signed (month, day, year)

HAVE YOU ATTACHED:
1. The skin care procedures that contain the consulting physician's original signature and date. 2. A copy of the handwashing procedures. 3. A copy of the form used to record the child's daily needs. 4. A copy of the form used for formula and other food requirements.

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SUPPLEMENTAL HEALTH CARE PROGRAM FOR CHILD CARE CENTERS PROVIDING INFANT-TODDLER CARE SUGGESTED FEEDING PLAN
State Form 49963 (R / 12-06) / BCC 0073

BUREAU OF CHILD CARE DIVISION OF FAMILY RESOURCES

INSTRUCTIONS: Prior to admission, a feeding plan shall be established and written for each infant (age 6 weeks - 12 months) in consultation with the parents and based on the written recommendation of the child's pediatrician or family physician. Feeding plans must be continually updated by physician or parent. [470 IAC 3-4.7 (b)] The following feeding plan has been recommended for this child.
Name of child Date of birth (month, day, year)

Age in Months

Time to Feed

Formula / Food Item and Amount

Special Instructions

Signature and Date of Parent or Physician

Signature of physician / nurse practitioner

Date signed (month, day, year)

FEEDING PLAN GUIDELINES INSTRUCTIONS: This is a guideline. Each child will grow at a different rate. 1. Formula and juice may be offered in a training cup when a child is ready. 2. Formula is used until 12 months unless otherwise stated by a physician. 3. Only plain, strained, mashed or chopped vegetables, fruits and meats are offered. 4. Most children are ready for foods of coarser consistency between 9 - 10 months of age. Mashed or chopped table foods may be used. 5. Strained or mashed foods should be introduced at 6 months if the infant's neuromuscular system has developed appropriately. Indications for solid foods are: the ability to swallow non-liquid foods, to sit with support, head and neck control, and to show that the child is full lean back or turn away. 6. Finger foods may be offered between 9 - 12 months when infant is developing finger / hand coordination. 2 MONTHS - 5 MONTHS TIME INTERVAL Month 2 6:00 a.m. 10:00 a.m. 2:00 p.m. 6:00 p.m. 10:00 p.m. 2:00 a.m. 4 - 6 oz. 4 - 6 oz. 4 - 6 oz. 4 - 6 oz. 4 - 6 oz. 4 - 6 oz. AMOUNT EACH FEEDING Month 3 Month 4 4 - 7 oz. 4 - 7 oz. 4 - 7 oz. 4 - 7 oz. 4 - 7 oz. 4 - 7 oz. 5 - 7 oz. 5 - 7 oz. 5 - 7 oz. 5 - 7 oz. 5 - 7 oz. 5 - 7 oz. Month 5 5 - 8 oz. 5 - 8 oz. 5 - 8 oz. 5 - 8 oz. 5 - 8 oz. 5 - 8 oz.

6 MONTHS - 12 MONTHS Month 6 T otal Amount of Formula Per 24 Hours 7:00 a.m. 30 - 48 oz. Month 7 30 - 32 oz. Month 8 29 - 31 oz. Month 9 26 - 31 oz. Months 10, 11, and 12 24 - 32 oz.

5 - 8 oz. formula 2 - 3T baby cereal *

6 oz. formula 2 - 3T baby cereal *

7 - 8 oz. formula 3 - 5T baby cereal *

7 - 8 oz. formula ** 4 - 6T baby cereal * 2 - 4T fruit

6 - 8 oz. formula ** (1cup) 1/4 - 1/2 baby cereal * 2 - 4T fruit 1/2 cup Vit. C fortified fruit juice 1/2 dry toast or 2 crackers 6 - 8 oz. formula ** (1 cup) 2T meat 2 - 6T potato, rice, noodles 5 - 9T vegetable 4 - 6T fruit 6 - 8 oz. formula ** (1 cup) 1/2 dry toast or 2 crackers 6 - 8 oz. formula ** (1 cup) 2T meat 2 - 6T potato, rice, noodles 2 - 4T vegetable 2 - 4T fruit

9:00 a.m.

5 - 8 oz. formula

6 oz. formula

1/2 cup Vit. C fortified fruit 1/2 cup Vit. C fortified fruit juice juice 1/4 dry toast or 1 cracker 1/2 dry toast or 2 crackers 7 - 8 oz. formula 5 - 9T vegetable 2 - 4T fruit 7 - 8 oz. formula ** 1 - 2T meat 5 - 9T vegetable 2 - 4T fruit

12:00 Noon

5 - 8 oz. formula 1/2 dry toast or 2 crackers

6 oz. formula 2 - 3T strained vegetable

3:00 p.m.

5 - 8 oz. formula

7 - 8 oz. formula 6 oz. formula 7 - 8 oz. formula ** 1/2 dry toast or 2 crackers 1/2 dry toast or 2 crackers 1/2 dry toast or 2 crackers 6 oz. formula 2 - 3T strained fruit 2 - 3T baby cereal * 7 - 8 oz. formula 5 - 9T vegetable 2 - 4T fruit 2 - 5T baby cereal * 7 - 8 oz. formula ** 5 - 9T vegetable 2 - 4T fruit 1T meat 4T baby cereal *

6:00 p.m.

5 - 8 oz. formula 2 - 3T baby cereal *

9:00 p.m.

5 - 8 oz. formula

May start sleeping through the night.

* If dry cereal is used, mix cereal and formula in a bowl. Feed with a spoon. ** Formula may be offered in a training cup.

SUPPLEMENTAL HEALTH PROGRAM FOR CHILD CARE CENTERS PROVIDING INFANT-TODDLER CARE HANDWASHING PROCEDURE
State Form 49961 (R / 12-06) / BCC 0074

BUREAU OF CHILD CARE DIVISION OF FAMILY RESOURCES

STEPS TO FOLLOW 1. Turn on water and adjust temperature to warm. 2. Wet hands thoroughly with running water. 3. Rinse soap if bar is used, and apply to hands.

KEY POINTS 1. Warm water must run throughout handwashing.

3. Antibacterial soaps may be used to help enhance the effectiveness of the procedure. 4. It is the friction which helps to remove much of the dirt and bacteria that is present.

4. Wash hands using friction and rotary motions.

5. Rinse hands well under running warm water. 6. Dry hands well with paper towel. 7. Turn off faucet with the paper towel. 6. Paper towels must be used. 7. Using a paper towel helps to avoid recontamination of clean hands.

Both children and staff must wash their hands: 1. Before and after eating. 2. After using the toilet.

IN ADDITION, STAFF MUST WASH THEIR HANDS AS FOLLOWS:
1. Before and after feeding a child. 2. Before serving food. 3. Before and after diaper changing. 4. After helping a child use the toilet. 5. After coughing, blowing nose, sneezing. 6. After coming in contact with body fluids. 7. Before and after giving first aid. 8. Before and after giving medication.

SUPPLEMENTAL HEALTH PROGRAM FOR CHILD CARE CENTERS PROVIDING INFANT-TODDLER CARE WEEKLY RECORD OF DAILY NEEDS
State Form 49960 (R / 12-06) / BCC 0075

BUREAU OF CHILD CARE DIVISION OF FAMILY RESOURCES

COPY TO PARENT or discuss on daily or weekly basis.
Name of child Special instructions for: (activity) (other)

A - ate well R - refused S - spit up V - vomited Food and Fluids Time and Amount Monday Staff Sig.

Urine B.M.

Awake Activities

Sleep # of Hours & Time

Mood: Happy, Crying, Quiet, Playful, etc.

Other: fever, skin rash, won't eat, still hungry, injury

Tuesday Staff Sig.

Wednesday Staff Sig.

Thursday Staff Sig.

Friday Staff Sig.

HEALTH CARE PROGRAM FOR CHILD CARE CENTERS PROCEDURE FOR SKIN CARE - DIAPERING
State Form 49971 (R / 10-06) / 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 Date signed (month, day, year)