"Children's Records Checklist" - Massachusetts

Children's Records Checklist is a legal document that was released by the Massachusetts Department of Early Education and Care - a government authority operating within Massachusetts.

Form Details:

  • Released on January 22, 2010;
  • The latest edition currently provided by the Massachusetts Department of Early Education and Care;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Massachusetts Department of Early Education and Care.

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The Commonwealth of Massachusetts
Department of Early Education and Care
Children’s Records Checklist
Child’s Name & Date of Birth
Face Sheet
Date of Admission
st
1
Aid/Emergency Medical
Consent & Release*
Off site consent*
On site swim consent*
Transportation Plan*
Medications
Individual Health Care Plans
(IHCP)
Referrals
Incident/Injury Report
Date of last Progress Report
Custody Agreements
Children Younger than School Age
Developmental History*
Date of last Physical Exam*
Lead screening
Immunizations
Developmental placement
Children Age 9 and Over
Consent to leave*
*Indicates fields which must be updated annually
Please refer to attached Instruction Page
SG/LG/SAChildRecordChecklist&Instructions20100122
The Commonwealth of Massachusetts
Department of Early Education and Care
Children’s Records Checklist
Child’s Name & Date of Birth
Face Sheet
Date of Admission
st
1
Aid/Emergency Medical
Consent & Release*
Off site consent*
On site swim consent*
Transportation Plan*
Medications
Individual Health Care Plans
(IHCP)
Referrals
Incident/Injury Report
Date of last Progress Report
Custody Agreements
Children Younger than School Age
Developmental History*
Date of last Physical Exam*
Lead screening
Immunizations
Developmental placement
Children Age 9 and Over
Consent to leave*
*Indicates fields which must be updated annually
Please refer to attached Instruction Page
SG/LG/SAChildRecordChecklist&Instructions20100122
Children’s Records Instructions
These instructions are to assist you in completing the required children’s records checklist. A copy of the
current checklist must be submitted to the licensor on the day of the licensing study. (Please note: if you leave
a blank space on the checklist, this will indicate that the information is not on file.)
1. Child’s Name: List all children by name and below each name indicate the child’s date of birth.
2. Face Sheet: Indicate with a √ that it is on file.
3. Date of Admission: Indicate the child’s date of admission into the program (this is significant for
progress report date and medical information).
4. First Aid /Emergency Hospital/Child Release: Indicate the date the consent form was signed by the
parent or guardian.
5. Off site Consent: Indicate with a √ that permission form(s) are on file for off-site activities.
6. On site Swimming Pool Permissions: For on-site swimming pool use, indicate the date the consent
form was signed by the parent or guardian.
7. Transportation Plan: Indicate the date the plan was signed by the parent or guardian.
8. Medication Records: If pertinent to the child, indicate with a √ that the information is on file.
9. Individual Health Care Plan (IHCP): If a child has an IHCP on file, record the date that the plan was
issued.
10. Referrals: If pertinent to the child, indicate with a √ that the information is on file.
11. Injury/Incident reports: If pertinent to the child, indicate with a √ that the information is on file.
12. Progress reports: Indicate the date of the last progress report on file.
13. Custody Agreements: Indicate with a √ if a custody agreement is on file.
Children Younger than School Age
14. Developmental History: Indicate with a √ that it is on file.
15. Physical Examination: Indicate the date of the last physical examination noted in the file.
16. Lead screening: If a child is younger than 9 months old, indicate NA (not applicable). If a child is 9
months or older, indicate with a √ that the documentation of lead screening is on file.
17. Immunization Records: Indicate with a √ if immunizations are on file and up to date.
18. Developmental Placement: Indicate the date that the child was placed in a group outside of their
chronological age.
School Age Child 9 Years and Older
19. Consent to Leave: Indicate the date the consent was signed by the parent or guardian.
SG/LG/SAChildRecordChecklist&Instructions20100122
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