DA Form 5761-2-r Family Child Care (Fcc) Risk Assessment Tool Interview Summary

DA Form 5761-2-r - also known as the "Family Child Care (fcc) Risk Assessment Tool Interview Summary" - is a United States Military form issued by the Department of the Army.

The form - often mistakenly referred to as the DD form 5761-2-r - was last revised on July 1, 1989. Download an up-to-date fillable PDF version of the DA 5761-2-r down below or look it up on the Army Publishing Directorate website.

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FAMILY CHILD CARE (FCC) RISK ASSESSMENT TOOL INTERVIEW 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 indicator interview. Rank each interview 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. At what age do you think a child should begin to feed himself?
1
2
3
4
5
2. What do you think children learn from punishment? What's the
1
2
3
4
5
difference between discipline and punishment? Please explain
what a spanking means to you.
3. How do you feel about regulations which don't allow punishment?
1
2
3
4
5
4. Do you and your husband agree on rules or limits for your children?
1
2
3
4
5
Who is the more strict?
5. If you give punishments, about how often do you give them?
1
2
3
4
5
6. If you spank your children, what do you spank with? How often
1
2
3
4
5
do you spank?
7. How do you feel about children lying? At what age do you think
1
2
3
4
5
children begin to lie deliberately?
8. When a parent is late picking up his or her child, how do you feel
1
2
3
4
5
about it? What do you do about it? How do you feel about saying
"No?"
9. When you have family child care problems, who do you talk to about
1
2
3
4
5
them? Who do you talk to about personal problems?
10. How is your spouse supportive to you as a child care provider?
1
2
3
4
5
As a person?
11. Who are your friends? What do you do for fun?
1
2
3
4
5
12. How do you spoil a child? Give two examples.
1
2
3
4
5
13. Do you have a VCR? Do you use it with the children? What kinds
1
2
3
4
5
of movies does your family watch--G, PG, R, X?
Provider Summary and Ranking
1
2
3
4
5
SECTION II - CHILDREN
14. How do you handle it when a child is sassy, talks back, swears,
1
2
3
4
5
calls you names?
15. What do you do when a child bites another child?
1
2
3
4
5
16. What do you think when you find two four-year-olds naked and
1
2
3
4
5
playing "doctor"? What do you do?
17. What do you do if a child hits or kicks other children? If he or she
1
2
3
4
5
hits or kicks you?
18. How do you help children to feel good about themselves and their
1
2
3
4
5
families?
19. If you have a difficult child in your care who is very hard to handle,
1
2
3
4
5
what do you do?
20. What do you do about the child who is "different" from the other
1
2
3
4
5
children, who has trouble fitting into the group?
21. How long does it take a child to adjust to child care?
1
2
3
4
5
Children's Summary and Rating
1
2
3
4
5
APD LC v2.01ES
DA FORM 5761-2-R, JUL 1989
FAMILY CHILD CARE (FCC) RISK ASSESSMENT TOOL INTERVIEW 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 indicator interview. Rank each interview 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. At what age do you think a child should begin to feed himself?
1
2
3
4
5
2. What do you think children learn from punishment? What's the
1
2
3
4
5
difference between discipline and punishment? Please explain
what a spanking means to you.
3. How do you feel about regulations which don't allow punishment?
1
2
3
4
5
4. Do you and your husband agree on rules or limits for your children?
1
2
3
4
5
Who is the more strict?
5. If you give punishments, about how often do you give them?
1
2
3
4
5
6. If you spank your children, what do you spank with? How often
1
2
3
4
5
do you spank?
7. How do you feel about children lying? At what age do you think
1
2
3
4
5
children begin to lie deliberately?
8. When a parent is late picking up his or her child, how do you feel
1
2
3
4
5
about it? What do you do about it? How do you feel about saying
"No?"
9. When you have family child care problems, who do you talk to about
1
2
3
4
5
them? Who do you talk to about personal problems?
10. How is your spouse supportive to you as a child care provider?
1
2
3
4
5
As a person?
11. Who are your friends? What do you do for fun?
1
2
3
4
5
12. How do you spoil a child? Give two examples.
1
2
3
4
5
13. Do you have a VCR? Do you use it with the children? What kinds
1
2
3
4
5
of movies does your family watch--G, PG, R, X?
Provider Summary and Ranking
1
2
3
4
5
SECTION II - CHILDREN
14. How do you handle it when a child is sassy, talks back, swears,
1
2
3
4
5
calls you names?
15. What do you do when a child bites another child?
1
2
3
4
5
16. What do you think when you find two four-year-olds naked and
1
2
3
4
5
playing "doctor"? What do you do?
17. What do you do if a child hits or kicks other children? If he or she
1
2
3
4
5
hits or kicks you?
18. How do you help children to feel good about themselves and their
1
2
3
4
5
families?
19. If you have a difficult child in your care who is very hard to handle,
1
2
3
4
5
what do you do?
20. What do you do about the child who is "different" from the other
1
2
3
4
5
children, who has trouble fitting into the group?
21. How long does it take a child to adjust to child care?
1
2
3
4
5
Children's Summary and Rating
1
2
3
4
5
APD LC v2.01ES
DA FORM 5761-2-R, JUL 1989
FAMILY CHILD CARE (FCC) RISK ASSESSMENT TOOL INTERVIEW SUMMARY CONT'D
SECTION III - MANAGEMENT
Rating for each question
22. Who comes in when you have an emergency or a scheduled
1
2
3
4
5
appointment during the day (you are sick, doctor's appointment)?
How did you choose this person?
23. How do your own children feel about your child care business?
1
2
3
4
5
If they are young, do they have problems with sharing? Are they
jealous? If older, do they have territorial problems?
24. How do you balance your family's needs with the needs of the child
1
2
3
4
5
care children? What adjustments have you all had to make to
have the business in your home?
25. What training have you had related to child care? Who does the
1
2
3
4
5
training? How have you used your training?
1
2
3
4
5
26. Do you belong to a provider support group, or an association?
Why or why not?
Management summary and rating
1
2
3
4
5
SECTION IV - BACKGROUND INFORMATION
27. In what ways were you punished or disciplined as a child? Did you
1
2
3
4
5
sometimes feel angry, fearful or ashamed?
28. If a person was abused as a child, would it have any effect on him
1
2
3
4
5
or her as an adult?
29. How do you feel about a person who has been abused?
1
2
3
4
5
1
2
3
4
5
How do you feel about a person who has been abusive?
30. Has alcohol or other drug use ever been a problem in your family?
1
2
3
4
5
Is it now?
Background information summary and rating
1
2
3
4
5
SECTION V - ORGANIZATIONAL CHECK
31. How often do you see your Outreach Worker? What does he or
1
2
3
4
5
she do on visits to your home?
32. How often do you see the FCC Director? On what occasions?
1
2
3
4
5
33. How often do you see the CDS Coordinator? On what occasions?
1
2
3
4
5
Organizational check summary and rating
1
2
3
4
5
COMMENTS
NAME OF FCC DIRECTOR/OUTREACH WORKER/IEPS
SIGNATURE OF FCC DIRECTOR/OUTREACH WORKER/EPS
APD LC v2.01ES
DA FORM 5761-2-R, JUL 1989
2

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