Form DHS-7743-ENG "Monthly Crib Safety Inspection Form for Family Child Care Providers" - Minnesota

What Is Form DHS-7743-ENG?

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

Form Details:

  • Released on June 1, 2014;
  • The latest edition provided by the Minnesota Department of Human 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 DHS-7743-ENG by clicking the link below or browse more documents and templates provided by the Minnesota Department of Human Services.

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Download Form DHS-7743-ENG "Monthly Crib Safety Inspection Form for Family Child Care Providers" - Minnesota

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DHS-7743-ENG
MONTHLY CRIB SAFETY INSPECTION FORM for FAMILY CHILD CARE PROVIDERS
Use one form per crib & Use reverse side for annual certification.
A. Crib’s brand name
B. Crib Model number
C. Crib number (if numbered)
A & B must be completed for every crib used or accessible to any child in care. If you do not have the cribs brand name and model number, the crib may not be used.
Effective December 28, 2012, the licensed program must maintain documentation that meets federal documentation requirements to show that every full-size and non-full-size crib that is used by or is accessible to
any child in care is compliant with federal crib standards under Code of Federal Regulations, title 16, part 1219, for full-size baby cribs, or Code of Federal Regulations, title 16, part 1220, for non-full-size baby cribs.
(Note inspection date under “date”. All items must be inspected each month. Document actions taken on back.)
Monthly Safety Inspection
Date
Date
Date
Date
Date
Date
Date
Date
Date
Date
Date
Date
Document date of review on this line (MM/DD/YEAR)
Cribs/Portable Cribs
Any product of rigid construction – wood, metal full size & non-full-size
1.
No mattress supports can be easily dislodged from any point of the crib
2.
No screws, bolts, or hardware are loose or not secured, and there is no
use of woodscrews in components that are designed to be assembled
and disassembled by the crib owner
3.
No sharp edges, points, or rough surfaces are present
4.
No wood surfaces are rough, splintered, split, or cracked
5.
No unacceptable gaps between the mattress and any sides of the crib are
present at any of the mattress support positions:
a.
When the noncompressed mattress is centered in the non-full-size
crib, the gap between the perimeter of the mattress and the crib is
not greater than ½ inch at any point.
b.
When the noncompressed mattress is placed against the perimeter
of the non-full-size crib, the resulting gap between the perimeter of
the mattress and the crib is not greater than 1 inch at any point.
c.
When the noncompressed mattress is centered in the full-size crib,
the gap between the perimeter of the mattress and the crib is not
greater than 11/16 inch at any point.
d.
When the noncompressed mattress is placed against the perimeter
of the full-size crib, the resulting gap between the perimeter of the
mattress and the crib is not greater than 1- 3/8 inch at any point.
6.
Crib sheet fits tightly on the firm mattress and overlaps mattress so it
cannot be dislodged by pulling on the corner of the sheet
Play Yards/Pack & Play/Play Pen Crib
Any product with mesh, net, screen, or fabric siding
1.
No tears, holes, or loose or unraveling threads in mesh or fabric sides
2.
No mesh weave is larger than ¼ inch
3.
No mesh is unsecure or unattached to top rail or floor plate
4.
No tears or holes to top rail of crib
5.
Mattress floor board is not soft and does not exceed 1 inch- -
only 1 mattress floor board in use
6.
No rips or tears in mattress floor board covering
7.
Mattress floor board is original and waterproof or replacement provided
by manufacturer of the crib
8.
No protruding or loose rivets, metal nuts, or bolts
9.
No knobs or wing nuts on outside crib legs
10. No missing, loose, or exposed staples
11. Latches on top and side rails are secure, lock properly, & are not loose
12. Crib sheet fits tightly on the firm mattress and overlaps mattress so it
cannot be dislodged by pulling on the corner of the sheet
Place a plus (+) for meets requirements or a minus (-) for does not meet requirements for each applicable item.
Upon discovery of any unsafe conditions during the safety inspection, immediately remove the crib from use and ensure the crib is not accessible to children. As soon as practicable, but not more than two business
days after the inspection, remove the crib from the area where child care services are routinely provided and make necessary repairs or destroy the crib. Manufacturers of mesh sided cribs do not recommend the
mesh be altered, therefore if there is a tear in the mesh, it cannot be repaired and may not be used. Document the action(s) taken regarding unsafe cribs on the reverse side of this form.
DHS-7743-ENG
MONTHLY CRIB SAFETY INSPECTION FORM for FAMILY CHILD CARE PROVIDERS
Use one form per crib & Use reverse side for annual certification.
A. Crib’s brand name
B. Crib Model number
C. Crib number (if numbered)
A & B must be completed for every crib used or accessible to any child in care. If you do not have the cribs brand name and model number, the crib may not be used.
Effective December 28, 2012, the licensed program must maintain documentation that meets federal documentation requirements to show that every full-size and non-full-size crib that is used by or is accessible to
any child in care is compliant with federal crib standards under Code of Federal Regulations, title 16, part 1219, for full-size baby cribs, or Code of Federal Regulations, title 16, part 1220, for non-full-size baby cribs.
(Note inspection date under “date”. All items must be inspected each month. Document actions taken on back.)
Monthly Safety Inspection
Date
Date
Date
Date
Date
Date
Date
Date
Date
Date
Date
Date
Document date of review on this line (MM/DD/YEAR)
Cribs/Portable Cribs
Any product of rigid construction – wood, metal full size & non-full-size
1.
No mattress supports can be easily dislodged from any point of the crib
2.
No screws, bolts, or hardware are loose or not secured, and there is no
use of woodscrews in components that are designed to be assembled
and disassembled by the crib owner
3.
No sharp edges, points, or rough surfaces are present
4.
No wood surfaces are rough, splintered, split, or cracked
5.
No unacceptable gaps between the mattress and any sides of the crib are
present at any of the mattress support positions:
a.
When the noncompressed mattress is centered in the non-full-size
crib, the gap between the perimeter of the mattress and the crib is
not greater than ½ inch at any point.
b.
When the noncompressed mattress is placed against the perimeter
of the non-full-size crib, the resulting gap between the perimeter of
the mattress and the crib is not greater than 1 inch at any point.
c.
When the noncompressed mattress is centered in the full-size crib,
the gap between the perimeter of the mattress and the crib is not
greater than 11/16 inch at any point.
d.
When the noncompressed mattress is placed against the perimeter
of the full-size crib, the resulting gap between the perimeter of the
mattress and the crib is not greater than 1- 3/8 inch at any point.
6.
Crib sheet fits tightly on the firm mattress and overlaps mattress so it
cannot be dislodged by pulling on the corner of the sheet
Play Yards/Pack & Play/Play Pen Crib
Any product with mesh, net, screen, or fabric siding
1.
No tears, holes, or loose or unraveling threads in mesh or fabric sides
2.
No mesh weave is larger than ¼ inch
3.
No mesh is unsecure or unattached to top rail or floor plate
4.
No tears or holes to top rail of crib
5.
Mattress floor board is not soft and does not exceed 1 inch- -
only 1 mattress floor board in use
6.
No rips or tears in mattress floor board covering
7.
Mattress floor board is original and waterproof or replacement provided
by manufacturer of the crib
8.
No protruding or loose rivets, metal nuts, or bolts
9.
No knobs or wing nuts on outside crib legs
10. No missing, loose, or exposed staples
11. Latches on top and side rails are secure, lock properly, & are not loose
12. Crib sheet fits tightly on the firm mattress and overlaps mattress so it
cannot be dislodged by pulling on the corner of the sheet
Place a plus (+) for meets requirements or a minus (-) for does not meet requirements for each applicable item.
Upon discovery of any unsafe conditions during the safety inspection, immediately remove the crib from use and ensure the crib is not accessible to children. As soon as practicable, but not more than two business
days after the inspection, remove the crib from the area where child care services are routinely provided and make necessary repairs or destroy the crib. Manufacturers of mesh sided cribs do not recommend the
mesh be altered, therefore if there is a tear in the mesh, it cannot be repaired and may not be used. Document the action(s) taken regarding unsafe cribs on the reverse side of this form.
DHS-7743-ENG
ANNUAL CERTIFICATION OF CRIB
(name and title) checked the crib’s brand name and
On
(date), I
model number listed on Page 1 against the U.S. Consumer Product Safety Commission Web site listing unsafe cribs.
(www.cpsc.gov)
The crib was not identified as unsafe on the U.S. Consumer Product Safety Commission Web site.
The crib was identified as unsafe on the U.S. Consumer Product Safety Commission Web site, but I have taken the action directed by
the United States Consumer Product Safety Commission to make the crib safe. (Identify all actions taken).
The crib was identified as unsafe on the U.S. Consumer Product Safety Commission Web site, and I have removed the crib
(date) so that the crib is no longer used by or accessible to children in care.
Maintain this document on site and make it available to parents of children in care and the commissioner upon request.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
MONTHLY SAFETY INSPECTION DOCUMENTATION
(Action(s) taken regarding unsafe cribs during the monthly crib safety inspections.)
Requirements: Minnesota Statutes, section 245A.146
June 2014
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