DSS Form 2972 "Supervisory Visit Form for Registered Church Child Care Centers" - South Carolina

What Is DSS Form 2972?

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

Form Details:

  • Released on April 1, 2009;
  • The latest edition provided by the South Carolina Department of Social 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 fillable version of DSS Form 2972 by clicking the link below or browse more documents and templates provided by the South Carolina Department of Social Services.

ADVERTISEMENT
ADVERTISEMENT

Download DSS Form 2972 "Supervisory Visit Form for Registered Church Child Care Centers" - South Carolina

Download PDF

Fill PDF online

Rate (4.5 / 5) 58 votes
Reset
South Carolina Department of Social Services
Office of Child Care Licensing and Regulatory Services
SUPERVISORY VISIT FORM FOR REGISTERED CHURCH CHILD CARE CENTERS
Date of Visit:
Time of Visit:
Type of Visit:
Supervisory
Corrective Action Plan
Complaint
ARL No.:
Hours of Operation:
Overnight Care?
Yes
No Facility Name:
Maximum Number of Children:
Center Director/Designee:
Number of Infants:
Change in Ownership or Director?
Yes
No
Items To Be Displayed:
License
Menu
Ratio Chart
Address:
Has the address changed?
Yes
No
Telephone No.:
Same?
Yes
No
114-523 H. Staffing
Date
Consent to
Non-
Name
Education
Training
Experience SLED
Hired
Release
Conviction
Is a staff member on the premises during all hours of operation that has current Infant/Child CPR and First-Aid certification?
Yes
No
114-523 H. (5) (f)
Name
Working Hours
First Aid
CPR
Certification Dates
114-524 Supervision
Child’s Age
Child
Staff
Caregiver
Child
Staff
Caregiver
Birth - One Year
One - Two Years
Two - Three Years
Three - Four Years
Four - Five Years
Five - Six Years
Six - Twelve Years
Is the center over-enrolled?
Yes
No
If yes, number of children over-enrolled:
Please Check All That Apply:
114-525 Health, Sanitation and Safety
Medicine and harmful items stored properly 114-525-D (2) (b)
Did you observe proper diaper changing practices? 114-525 F. (1)
First Aid supplies in facility 114-525 E (1)
114-527 Physical Site
Lighting and ventilation sufficient 114-527 A. (4) (c) and (2) (a)
Adequate cushioning materials; at least 6 ft. fall zone
114-527. C. (8)
Carpet, ceiling, floor, rugs, properly secured 114-527 A. 5 (d)
Fencing, safety barriers proper height, in good repair
Does at least one sink have hot and cold water 114-527 A. (12) (d)
114-527 A. (5) (a)
Did you observe soap and towels in restrooms 114-527 A. (12) (i)
Grounds free of hazards and other litter 114-527 B. (2)
Cots, beds, mats, cribs, for each child 114-527 D. (2)
Garbage and refuse stored properly in hands-free, plastic lined
Building(s) adequately heated or cooled 114-527 A. (7) (a)
receptacle 114-527 A. (8) (d-f)
Playground equipment safe and in good condition 114-527 C. (6-7)
Pest control for insects and rodents 114-527 E. (1) (e)
Did you observe any items that may cause strangulation, choking
or suffocation? 114-527 A. (5) (g) (i-iii)
114-528 Meal Requirements
Food stored and handled properly 114-528 D. (1)
Round firm food served 114-528 A. (3)
Served to children under 4 years
Refrigerators have thermometers 114-528 D. (3)
114-529 Infant Care
Did you observe infants being placed on their backs? 114-529 A. (3) (a)
Is the microwave used to heat formula? 114-529 A. (1) (d)
Did you observe bottles being propped? 114-529 A. (1) (c)
Does the facility have a history of non-compliance with training?
Yes
No
If yes, check training hours.
Are there deficiencies?
Yes
No
If yes, please attach DSS 2942 and if any pending determination indicate below.
Comments:
Signature of Director/Operator/Designee:
Date:
Signature of Senior Child Care Specialist:
Date:
* Indicates determination is pending
DSS Form 2972 (APR 09)
Reset
South Carolina Department of Social Services
Office of Child Care Licensing and Regulatory Services
SUPERVISORY VISIT FORM FOR REGISTERED CHURCH CHILD CARE CENTERS
Date of Visit:
Time of Visit:
Type of Visit:
Supervisory
Corrective Action Plan
Complaint
ARL No.:
Hours of Operation:
Overnight Care?
Yes
No Facility Name:
Maximum Number of Children:
Center Director/Designee:
Number of Infants:
Change in Ownership or Director?
Yes
No
Items To Be Displayed:
License
Menu
Ratio Chart
Address:
Has the address changed?
Yes
No
Telephone No.:
Same?
Yes
No
114-523 H. Staffing
Date
Consent to
Non-
Name
Education
Training
Experience SLED
Hired
Release
Conviction
Is a staff member on the premises during all hours of operation that has current Infant/Child CPR and First-Aid certification?
Yes
No
114-523 H. (5) (f)
Name
Working Hours
First Aid
CPR
Certification Dates
114-524 Supervision
Child’s Age
Child
Staff
Caregiver
Child
Staff
Caregiver
Birth - One Year
One - Two Years
Two - Three Years
Three - Four Years
Four - Five Years
Five - Six Years
Six - Twelve Years
Is the center over-enrolled?
Yes
No
If yes, number of children over-enrolled:
Please Check All That Apply:
114-525 Health, Sanitation and Safety
Medicine and harmful items stored properly 114-525-D (2) (b)
Did you observe proper diaper changing practices? 114-525 F. (1)
First Aid supplies in facility 114-525 E (1)
114-527 Physical Site
Lighting and ventilation sufficient 114-527 A. (4) (c) and (2) (a)
Adequate cushioning materials; at least 6 ft. fall zone
114-527. C. (8)
Carpet, ceiling, floor, rugs, properly secured 114-527 A. 5 (d)
Fencing, safety barriers proper height, in good repair
Does at least one sink have hot and cold water 114-527 A. (12) (d)
114-527 A. (5) (a)
Did you observe soap and towels in restrooms 114-527 A. (12) (i)
Grounds free of hazards and other litter 114-527 B. (2)
Cots, beds, mats, cribs, for each child 114-527 D. (2)
Garbage and refuse stored properly in hands-free, plastic lined
Building(s) adequately heated or cooled 114-527 A. (7) (a)
receptacle 114-527 A. (8) (d-f)
Playground equipment safe and in good condition 114-527 C. (6-7)
Pest control for insects and rodents 114-527 E. (1) (e)
Did you observe any items that may cause strangulation, choking
or suffocation? 114-527 A. (5) (g) (i-iii)
114-528 Meal Requirements
Food stored and handled properly 114-528 D. (1)
Round firm food served 114-528 A. (3)
Served to children under 4 years
Refrigerators have thermometers 114-528 D. (3)
114-529 Infant Care
Did you observe infants being placed on their backs? 114-529 A. (3) (a)
Is the microwave used to heat formula? 114-529 A. (1) (d)
Did you observe bottles being propped? 114-529 A. (1) (c)
Does the facility have a history of non-compliance with training?
Yes
No
If yes, check training hours.
Are there deficiencies?
Yes
No
If yes, please attach DSS 2942 and if any pending determination indicate below.
Comments:
Signature of Director/Operator/Designee:
Date:
Signature of Senior Child Care Specialist:
Date:
* Indicates determination is pending
DSS Form 2972 (APR 09)