Form CFS2026 "Home Safety Checklist for Parents and Caregivers" - Illinois

What Is Form CFS2026?

This is a legal form that was released by the Illinois Department of Children and Family Services - a government authority operating within Illinois. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 1, 2015;
  • The latest edition provided by the Illinois Department of Children and Family Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form CFS2026 by clicking the link below or browse more documents and templates provided by the Illinois Department of Children and Family Services.

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Download Form CFS2026 "Home Safety Checklist for Parents and Caregivers" - Illinois

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CFS 2026
State of Illinois
Revised 10/2015
Department of Children and Family Services
HOME SAFETY CHECKLIST FOR PARENTS AND CAREGIVERS
Date Checklist completed:
Parent /Caregiver Name(s):
Parent / Caregiver Address:
Names and ages of Children in the Home:
Every year, 120,000 children suffer some form of permanent damage due to accidental injuries, such as permanent brain damage from a head
injury, long-term breathing problems from smoke inhalation, disfigurement from burns, or liver or kidney damage from poisoning. According to
data from the National SAFE KIDS Campaign:
Accidental or unintentional injury is the leading cause of death among children, teens and young adults.
The five leading causes of accidental injury are drowning, burns, motor vehicle accidents, falls, and poisonings.
Burns and fires are the fourth most common causes of accidental death in children.
Nearly 75 percent of all burns in children are preventable.
Nearly 2,900 adults and children die every year in fires or from other burn injuries.
Toddlers and children are more often burned by a scalding or flames.
The majority of children ages four and under, who are hospitalized for burn-related injures, suffer from scald burns (65 percent) or contact
burns (20 percent).
Hot tap water burns cause more deaths and hospitalizations than burns from any other hot liquids.
Fire/burns, motor vehicle traffic accidents, suffocation and accidental falls are the leading causes of unintentional deaths of children
under the age of five in Illinois. Numerous Illinois children also die each year as a result of domestic violence.
While it may be impossible to eliminate all the dangers children encounter in their homes, one of the most important factors in reducing those
hazards is knowledge. The Home Safety Checklist will help you identify any hazards that may exist in your home.
(1)
CFS 2026
State of Illinois
Revised 10/2015
Department of Children and Family Services
HOME SAFETY CHECKLIST FOR PARENTS AND CAREGIVERS
Date Checklist completed:
Parent /Caregiver Name(s):
Parent / Caregiver Address:
Names and ages of Children in the Home:
Every year, 120,000 children suffer some form of permanent damage due to accidental injuries, such as permanent brain damage from a head
injury, long-term breathing problems from smoke inhalation, disfigurement from burns, or liver or kidney damage from poisoning. According to
data from the National SAFE KIDS Campaign:
Accidental or unintentional injury is the leading cause of death among children, teens and young adults.
The five leading causes of accidental injury are drowning, burns, motor vehicle accidents, falls, and poisonings.
Burns and fires are the fourth most common causes of accidental death in children.
Nearly 75 percent of all burns in children are preventable.
Nearly 2,900 adults and children die every year in fires or from other burn injuries.
Toddlers and children are more often burned by a scalding or flames.
The majority of children ages four and under, who are hospitalized for burn-related injures, suffer from scald burns (65 percent) or contact
burns (20 percent).
Hot tap water burns cause more deaths and hospitalizations than burns from any other hot liquids.
Fire/burns, motor vehicle traffic accidents, suffocation and accidental falls are the leading causes of unintentional deaths of children
under the age of five in Illinois. Numerous Illinois children also die each year as a result of domestic violence.
While it may be impossible to eliminate all the dangers children encounter in their homes, one of the most important factors in reducing those
hazards is knowledge. The Home Safety Checklist will help you identify any hazards that may exist in your home.
(1)
CFS 2026
State of Illinois
Revised 10/2015
Department of Children and Family Services
HOME SAFETY CHECKLIST FOR PARENTS AND CAREGIVERS
FIRE and BURNS
Please circle your answers.
PARENTS’ GUIDE to Fire Safety for Babies and Toddlers
Literature Received:
Yes
No
A HELPFUL GUIDE for PARENTS and CAREGIVERS
Literature Received:
Yes
No
1. My home has a working smoke detector.
Discussed with worker? Yes
No
2. The smoke detector is located near my family’s sleeping areas.
Discussed with worker? Yes
No
3. I know how to test and replace the smoke detector battery.
Discussed with worker? Yes
No
4. My family has a fire escape plan.
Discussed with worker? Yes
No
5. We practice the plan so that we can respond quickly in case there is a fire.
Discussed with worker? Yes
No
Young children in Illinois are more than three times as likely to die in a residential fire as the rest of the state’s population. Working smoke
detectors save lives! Change smoke detector batteries when resetting your clocks in the spring and fall; SPRING AHEAD and FALL BACK. I do
not have the means to purchase new or repair non-working smoke detectors. I have completed and signed the CFS 595-2, Consent for
Installation of Smoke Alarm(s) form. The worker will fax the completed form as instructed on the bottom of the CFS 595-2. A smoke detector
will be provided at no cost to my family.
6. My preschoolers and younger children do not have access to matches or lighters.
Discussed with worker? Yes
No
N/A
7. I never use my stove oven or burners to heat my home.
Discussed with worker? Yes
No
Forty percent of residential fire related deaths among children are caused by child fire-play. Up to two thirds of child fire-play victims are not the
children who were playing with and/or started the fire. Supervision of children will prevent fire-play as well as other accidents. Home heating
systems are a leading cause of home fires, and alternative home heating sources such as electric space heaters, kerosene heaters and wood stoves
are a major cause of fire deaths. Electric space heaters should be approved by the Underwriters Laboratories (UL), have a thermostat control
mechanism, and switch off automatically if the heater falls over. Heaters are not clothes dryers or tables. Keep the heater three feet from
combustible materials such as furniture, curtains, blankets, paper, and walls; and unplug the heater when it is not in use. Kerosene heaters should
also be UL approved. Never fill a kerosene heater with gasoline or camp stove fuel; both flare-up easily. Only use crystal clear K-1 kerosene.
Use the kerosene heater in a well ventilated room and away from combustible materials. Check wood stoves for cracks and inspect legs, hinges
and door seals for smooth joints and seams. Burn only seasoned wood, not green wood, artificial logs or trash. Be sure to keep combustible
materials at least three feet away from a wood stove.
(2)
CFS 2026
State of Illinois
Revised 10/2015
Department of Children and Family Services
HOME SAFETY CHECKLIST FOR PARENTS AND CAREGIVERS
8.
The hot water in my home does not come out of the tap at scalding temperatures.
Discussed with worker? Yes
No
To measure your hot water temperature, place a thermometer under the stream of water from a kitchen or bathroom faucet. Hold the thermometer
in the stream of water until the recorded temperature stops rising. The water temperature may be measured with outdoor, candy, or digital
thermometers. Your hot water heater should be set no higher than 120° Fahrenheit to prevent scald burns to children. Children’s skin is thinner
than an adult’s skin, and infants and young children will suffer partial and full-thickness (second and third degree) burns after ten seconds in 130°
F water; four seconds in 135° F water; one second in 140° F water, and one half second in 149° F water. The correct temperature for an infant’s
bath water is between 96.8° and 102.2° F. Never place your child in a bath or under running water without first checking the temperature of the
water.
9. I do not keep hot items, such as those listed below, within the reach of my infant,
Discussed with worker?
Yes
No
N/A
toddler or younger child.
10. I always turn pot handles towards the back of the stove when they are on the stove.
Discussed with worker?
Yes
No
N/A
The majority of scald burns to children, especially among those ages six months to two years, are from hot foods and liquids spilled in the kitchen.
Kitchens can be especially dangerous for children during meal preparation. Hot items such as coffee, tea, water, food, pots and pans, and lit
cigarettes should never be left on tables, countertops or stove tops within the reach of a child. You should not hold your child while you are
cooking.
11. I keep electrical appliances (e.g., hair dryers, curling and clothes irons) out of
Discussed with worker?
Yes
No
N/A
reach of my younger children.
Discussed with worker?
Yes
No
12. I never plug multiple electrical items into a single plug electrical outlet.
Children have been burned by appliances they have pulled down onto themselves. Children have also electrocuted themselves by dropping
appliances into water.
13. I do not place extension cords under rugs or furniture.
Discussed with worker?
Yes
No
Extension cords can wear out and spark. They will quickly cause a fire if they are placed under rugs or furniture.
14. The electrical outlets are covered when not in use to protect my toddlers and
Discussed with worker?
Yes
No
N/A
younger children from electrical shock.
Children can be electrocuted if they place small objects in electrical sockets.
(3)
CFS 2026
State of Illinois
Revised 10/2015
Department of Children and Family Services
HOME SAFETY CHECKLIST FOR PARENTS AND CAREGIVERS
SLEEPING
Back to Sleep
Literature Received:
Yes
No
15. My infant sleeps alone in a crib or bassinette.
Discussed with worker?
Yes
No
N/A
16. My infant does not sleep in his or her crib with toys, stuffed animals or pillows.
Discussed with worker?
Yes
No
N/A
17. My infant is always placed on his or her back to sleep.
Discussed with worker?
Yes
No
N/A
When an infant is in the crib, the sides of the crib must be up; the mattress must be in the low position; the crib must not be placed near a window;
window blinds; electrical cords must be out of the reach of the child; and pillows, stuffed animals and toys must never be left in the crib with the
child. A child must never wear a pacifier on a ribbon or string placed around his or her neck.
CHOKING
18. Plastic bags, pins, buttons, coins, balloons and sharp or breakable items are kept
Discussed with worker? Yes
No
N/A
out of the reach of my children.
19. My younger children only play with toys that are too large to swallow,
Discussed with worker? Yes
No
N/A
unbreakable and without sharp edges or points.
Food such as hot dogs, hard candy, grapes, popcorn and nuts are common culprits in choking deaths. Small toys, tiny rubber balls, too small
pacifiers, and bits of balloons are common non-food choking hazards. Children are also at risk for becoming entangled in the ties on hoods, cords
that control window blinds, toys strung across cribs, and strings used to attach pacifiers to clothing. As a general rule, any toy that can fit in a
toilet paper roll is a choking hazard.
DROWNING
Get water wise…. SUPERVISE
Literature Received:
Yes No
20. My infant and/or toddler are never left alone when near a bath, pool, bucket or
Discussed with worker?
Yes
No
N/A
toilet.
21. I always drain the baby pool when not in use.
Discussed with worker?
Yes
No
N/A
22. I always supervise my children when they are in or near water.
Discussed with worker?
Yes
No
N/A
(4)
CFS 2026
State of Illinois
Revised 10/2015
Department of Children and Family Services
HOME SAFETY CHECKLIST FOR PARENTS AND CAREGIVERS
A young child can drown in as little as one inch of water. More than half of the drowning victims under the age of one drown in the bathtub
during a brief lapse of supervision by the child’s parent or caregiver. A child will lose consciousness within two minutes following submersion.
Children must always be supervised when they are near water.
FALLS
23. I never leave my infant or toddler alone while they are on changing tables, tables,
Discussed with worker?
Yes
No
N/A
countertops, etc.
24. I do not have any furniture that my toddler and younger children can climb on
Discussed with worker?
Yes
No
N/A
placed near a window.
Discussed with worker?
Yes
No
N/A
25. I do no use a baby walker.
Children are likely to die or be severely injured from window-related falls. Children are curious and may try to crawl out of an open window. A
screen is not strong enough to hold a child who is leaning against it. Screens are designed to keep insects out of the home, not to keep children
from falling out of the window. Children jumping on beds are at risk of falling out open windows. Supervision is the key to keeping children safe
from injury. A window that is open four inches or more is potentially dangerous to children.
0”
1”
2”
3”
4”
POISON
26. I keep cleaning products, pesticides, medicine and liquor out of the reach of
Discussed with worker?
Yes
No
children.
27. I do not keep any of the products listed below in food containers or soft drink
Discussed with worker?
Yes
No
bottles.
28. Paint is not chipping or pealing off the walls or woodwork of my home.
Discussed with worker?
Yes
No
29. There are no rats or mice in my home.
Discussed with worker?
Yes
No
30. Rodent poisons are not placed within the reach my infant, toddler or younger
Discussed with worker?
Yes
No
N/A
children.
31. My toddler and younger children do not have access to rotten food/trash.
Discussed with worker?
Yes
No
N/A
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