DA Form 5761-3-r Family Child Care (FCC) Risk Assessment Tool Report

DA Form 5761-3-r - also known as the "Family Child Care (fcc) Risk Assessment Tool Report" - is a Military form issued and used by the United States Department of the Army.

The form - often mistakenly referred to as the DD form 5761-3-r - was last revised on July 1, 1989. Download an up-to-date fillable PDF version of the DA 5761-3-r below or request a copy through the chain of command.

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FAMILY CHILD CARE (FCC) RISK ASSESSMENT TOOL REPORT
For use of this form, see AR 608-10; the proponent agency is DCSPER
SEE DA FORM 5761-R FOR PRIVACY ACT STATEMENT
NUMBER OF CHILDREN IN
NAME OF PROVIDER
AGES OF CHILDREN
ATTENDANCE
SPECIAL NOTATIONS (handicapped child, helpers, etc.)
1. Based on observation and interview questions, do you have any areas of concern about this provider (e.g, childhood experiences, current
support system, child development knowledge)? Explain
2. Using information from the observation and the interview, summarize the areas in which this provider may demonstrate low risk for potential
abuse/high quality care:
3. Using information from the observation and the interview, summarize the areas in which this provider may demonstrate moderate risk for
potential abuse/moderate quality care:
4. Using information from the observation and the interview, summarize the areas in which this provider may demonstrate high risk for potential
abuse/low quality care:
5. Recommendations for training, consultation or follow-up needed, action to be taken:
6. We recommend:
Full certification
and/or the following action:
7. NAME OF OUTREACH WORKER
8.
SIGNATURE OF OUTREACH WORKER
9. DATE
10. NAME OF FCC DIRECTOR
11. SIGNATURE OF FCC DIRECTOR
12. DATE
13. NAME OF CDS COORDINATOR
14. SIGNATURE OF CDS COORDINATOR
15. DATE
DA FORM 5761-3-R, JUL 1989
APD LC v2.00
FAMILY CHILD CARE (FCC) RISK ASSESSMENT TOOL REPORT
For use of this form, see AR 608-10; the proponent agency is DCSPER
SEE DA FORM 5761-R FOR PRIVACY ACT STATEMENT
NUMBER OF CHILDREN IN
NAME OF PROVIDER
AGES OF CHILDREN
ATTENDANCE
SPECIAL NOTATIONS (handicapped child, helpers, etc.)
1. Based on observation and interview questions, do you have any areas of concern about this provider (e.g, childhood experiences, current
support system, child development knowledge)? Explain
2. Using information from the observation and the interview, summarize the areas in which this provider may demonstrate low risk for potential
abuse/high quality care:
3. Using information from the observation and the interview, summarize the areas in which this provider may demonstrate moderate risk for
potential abuse/moderate quality care:
4. Using information from the observation and the interview, summarize the areas in which this provider may demonstrate high risk for potential
abuse/low quality care:
5. Recommendations for training, consultation or follow-up needed, action to be taken:
6. We recommend:
Full certification
and/or the following action:
7. NAME OF OUTREACH WORKER
8.
SIGNATURE OF OUTREACH WORKER
9. DATE
10. NAME OF FCC DIRECTOR
11. SIGNATURE OF FCC DIRECTOR
12. DATE
13. NAME OF CDS COORDINATOR
14. SIGNATURE OF CDS COORDINATOR
15. DATE
DA FORM 5761-3-R, JUL 1989
APD LC v2.00

Download DA Form 5761-3-r Family Child Care (FCC) Risk Assessment Tool Report

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