DA Form 5761-1-r Family Child Care Risk Assessment Tool Observation Summary

DA Form 5761-1-r - also known as the "Family Child Care Risk Assessment Tool Observation Summary" - is a United States Military form issued by the Department of the Army.

The form - often mistakenly referred to as the DD form 5761-1-r - was last revised on July 1, 1989. Download an up-to-date fillable PDF version of the DA 5761-1-r down below or look it up on the Army Publishing Directorate website.

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FAMILY CHILD CARE (FCC) RISK ASSESSMENT TOOL OBSERVATION SUMMARY
For use of this form, see AR 608-10; the proponent agency is DCS, G-1.
SEE DA FORM 5761-R FOR PRIVACY ACT STATEMENT
Please use this form to summarize the risk level in each category of the observation instrument. Rank each
observation question, then give an overall ranking and briefly summarize the provider's strengths and areas of risk
for each risk category.
NAME OF PROVIDER
SECTION I - PROVIDER
Rating for each question
1. Describe what happens when you first arrive.
1
2
3
4
5
2. Who is in the house when you arrive?
1
2
3
4
5
3. Describe how the provider handles interruptions.
1
2
3
4
5
4. How does the provider handle crises, emergencies, the unexpected?
1
2
3
4
5
5. Describe the husband's presence/involvement in the day-to-day
1
2
3
4
5
operations of the FCC home.
6. How are the provider's own children involved in the FCC program?
1
2
3
4
5
Provider Summary and Ranking
1
2
3
4
5
SECTION II - PROVIDER-CHILD INTERACTIONS
7. How do the children behave around the provider and her family?
1
2
3
4
5
8. How does the provider care for children of differing ages, abilities
1
2
3
4
5
and interests?
9. How does the provider react when a child breaks the rules?
1
2
3
4
5
10. How does the provider speak to a child who is misbehaving?
1
2
3
4
5
11. What type of physical contact does the provider have with a child
1
2
3
4
5
who is misbehaving?
12. How does the provider react to a child who is crying?
1
2
3
4
5
13. Describe what happens at meal time.
1
2
3
4
5
14. How does the provider react to a child who has a toileting accident?
1
2
3
4
5
15. Describe the provider's diapering procedures?
1
2
3
4
5
16. Describe any instances of children who display behavior problems.
1
2
3
4
5
Provider-Child Interaction Summary and Ranking
1
2
3
4
5
SECTION III - SUPERVISION
1
2
3
4
5
17. Where are the children during your visit?
18. Describe the type of indoor activities you see.
1
2
3
4
5
19. Describe the type of outdoor activities you see.
1
2
3
4
5
1
2
3
4
5
20. How does the provider use TV with the children, and for herself?
21. How does the provider keep children away from dangerous things
1
2
3
4
5
and/or personal possessions?
22. How are older children involved in the care and supervision of
1
2
3
4
5
younger children?
23. Describe what happens at nap time.
1
2
3
4
5
Supervision Summary and Rating
1
2
3
4
5
DA FORM 5761-1-R, JUL 1989
APD LC v2.01ES
FAMILY CHILD CARE (FCC) RISK ASSESSMENT TOOL OBSERVATION SUMMARY
For use of this form, see AR 608-10; the proponent agency is DCS, G-1.
SEE DA FORM 5761-R FOR PRIVACY ACT STATEMENT
Please use this form to summarize the risk level in each category of the observation instrument. Rank each
observation question, then give an overall ranking and briefly summarize the provider's strengths and areas of risk
for each risk category.
NAME OF PROVIDER
SECTION I - PROVIDER
Rating for each question
1. Describe what happens when you first arrive.
1
2
3
4
5
2. Who is in the house when you arrive?
1
2
3
4
5
3. Describe how the provider handles interruptions.
1
2
3
4
5
4. How does the provider handle crises, emergencies, the unexpected?
1
2
3
4
5
5. Describe the husband's presence/involvement in the day-to-day
1
2
3
4
5
operations of the FCC home.
6. How are the provider's own children involved in the FCC program?
1
2
3
4
5
Provider Summary and Ranking
1
2
3
4
5
SECTION II - PROVIDER-CHILD INTERACTIONS
7. How do the children behave around the provider and her family?
1
2
3
4
5
8. How does the provider care for children of differing ages, abilities
1
2
3
4
5
and interests?
9. How does the provider react when a child breaks the rules?
1
2
3
4
5
10. How does the provider speak to a child who is misbehaving?
1
2
3
4
5
11. What type of physical contact does the provider have with a child
1
2
3
4
5
who is misbehaving?
12. How does the provider react to a child who is crying?
1
2
3
4
5
13. Describe what happens at meal time.
1
2
3
4
5
14. How does the provider react to a child who has a toileting accident?
1
2
3
4
5
15. Describe the provider's diapering procedures?
1
2
3
4
5
16. Describe any instances of children who display behavior problems.
1
2
3
4
5
Provider-Child Interaction Summary and Ranking
1
2
3
4
5
SECTION III - SUPERVISION
1
2
3
4
5
17. Where are the children during your visit?
18. Describe the type of indoor activities you see.
1
2
3
4
5
19. Describe the type of outdoor activities you see.
1
2
3
4
5
1
2
3
4
5
20. How does the provider use TV with the children, and for herself?
21. How does the provider keep children away from dangerous things
1
2
3
4
5
and/or personal possessions?
22. How are older children involved in the care and supervision of
1
2
3
4
5
younger children?
23. Describe what happens at nap time.
1
2
3
4
5
Supervision Summary and Rating
1
2
3
4
5
DA FORM 5761-1-R, JUL 1989
APD LC v2.01ES
FAMILY CHILD CARE
(FCC) RISK ASSESSMENT TOOL OBSERVATION SUMMARY (CONT'D)
SECTION IV - ENVIRONMENT
Rating for each question
24. Describe the condition and appearance of the house.
1
2
3
4
5
25. What type of space is provided for the children?
1
2
3
4
5
26. Could unknown adults and adolescents have access to children
because of problems with the facility?
1
2
3
4
5
27. Could unknown adults and adolescents have access to children
because of lack of supervision?
1
2
3
4
5
28. Could adults and adolescents known to the provider have an
opportunity to abuse children because of the choice of substitutes
or helpers?
1
2
3
4
5
29. Could adults and adolescents known to the provider have an
opportunity to abuse children because of lack of supervision?
1
2
3
4
5
Environment Summary and Rating
1
2
3
4
5
SECTION V - PROVIDER-PARENT INTERACTIONS
30. What type of communication does the provider have with the
1
2
3
4
5
parents of the children in her care?
31. What type of contracts does the provider have between herself and
the parents of the children in her care?
1
2
3
4
5
32. How does the provider react when a parent is late to pick up
1
2
3
4
5
his/her child?
33. How does the provider handle fee disputes with parents?
1
2
3
4
5
34. Describe the provider's methods for keeping daily attendance
records.
1
2
3
4
5
Provider-Parent Interaction Summary and Rating
1
2
3
4
5
SECTION VI - ADMINISTRATIVE INTERACTIONS
Ask the provider to show you the following administrative forms,
and evaluate each for comprehensiveness.
35. Emergency/contingency plan.
1
2
3
4
5
36. Discipline policy.
1
2
3
4
5
37. Parental authorization regarding which other adults may pick up
1
2
3
4
5
children.
38. Sick Child/Health Policy.
1
2
3
4
5
39. How would you describe the provider's relationship with her out-
reach worker?
1
2
3
4
5
Administrative Interaction Summary and Ratings
1
2
3
4
5
COMMENTS
NAME OF FCC DIRECTOR/OUTREACH WORKER/EPS
SIGNATURE OF FCC DIRECTOR/OUTREACH WORKER/EPS
DATE
DA FORM 5761-1-R, JUL 1989
2
APD LC v2.01ES

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