"Family Interview Form for Babysitters"

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Family Interview Form
Family Information and Emergency Numbers
Today’s date: ____________________________________________________________
Family name: ____________________________________________________________
Home phone number: _____________________________________________________
Address: ________________________________________________________________
E-mail address: ___________________________________________________________
Nearest cross-street: ______________________________________________________
Phone number where parent can be reached during babysitting job: ______________
Medical
Child’s name
Age
Weight
Medicines
Allergies
problems
Mobile phone number: ____________________________________________________
Neighbor’s name and phone number: ________________________________________
Name and phone number of an adult who can make decisions if the parent cannot
be reached: _____________________________________________________________
Local emergency phone number: ___________________________________________
Doctor’s name: ___________________________________________________________
Doctor’s phone number: ___________________________________________________
Name of preferred hospital to be used in an emergency: _________________________
National Poison Control Center (PCC) hotline: (800) 222-1222
FA M I LY I N T E R V I E W F O R M
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Family Interview Form
Family Information and Emergency Numbers
Today’s date: ____________________________________________________________
Family name: ____________________________________________________________
Home phone number: _____________________________________________________
Address: ________________________________________________________________
E-mail address: ___________________________________________________________
Nearest cross-street: ______________________________________________________
Phone number where parent can be reached during babysitting job: ______________
Medical
Child’s name
Age
Weight
Medicines
Allergies
problems
Mobile phone number: ____________________________________________________
Neighbor’s name and phone number: ________________________________________
Name and phone number of an adult who can make decisions if the parent cannot
be reached: _____________________________________________________________
Local emergency phone number: ___________________________________________
Doctor’s name: ___________________________________________________________
Doctor’s phone number: ___________________________________________________
Name of preferred hospital to be used in an emergency: _________________________
National Poison Control Center (PCC) hotline: (800) 222-1222
FA M I LY I N T E R V I E W F O R M
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Household Rules and Discipline
1. What are the household rules?
2. How would you like me to handle misbehavior?
3. Do the children need to complete any homework or chores? If so, when should the children
complete their homework or chores? Will they need assistance?
Safet y and Play
1. Would you take me on a tour of your house?
2. I would like to go over the Safety Inspection Checklist with you. Is that okay?
3. Does your family have a fi re escape plan? If not, can you have one in place before I begin?
4. Do your children know what to do in a fi re emergency?
Not e: Families can fi nd out more about how to be prepared for fi res and ot her emergencies by
contacting their local American Red Cross chapter or visiting
www.redcross.org/disaster/masters/.
5. Does your house have working smoke alarms? Carbon monoxide alarm? Fire extinguisher?
Where is the shut-off valve for water, electricity and gas?
6. Is it okay to take the children outside to play?
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FA M I LY I N T E R V I E W F O R M
7. Should I apply insect repellant or sunscreen to the children before they play outside? If so, what
insect repellant or sunscreen should I use? Do any of the children have allergies or sensitivities to
any of them?
8. Do you have any pets that I need to care for? Are they friendly to strangers?
9. May I meet your children (and pets) before I babysit?
10. What are your family’s rules for play? What are your family’s rules for watching TV, using
the computer and playing video games?
11. What are your children’s favorite toys and play activities?
12. Are there any play areas, toys or activities that are off -limits or restricted?
13. How do I work the door and window locks?
14. Do you have an electronic security system? Would you like me to use it and can you
please show me how it works? What should I do if it is mistakenly set off ?
15. Where is your fi rst aid kit kept?
FA M I LY I N T E R V I E W F O R M
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16. Where is your emergency preparedness kit kept?
Not e: Families can fi nd out more about how to prepare for emergencies by contacting their
local American Red Cross chapter or visiting
www.redcross.org/disaster/masters/.
17. Is there a spare house key for me to use?
Basic Child Care
1. How do you want me to handle hand washing?
2. How do you want me to handle brushing and fl ossing teeth?
3. What can your children eat and drink? Do they have any food allergies?
4. Will I be preparing any simple meals?
5. What are the routines for diapering and/or using the toilet? Where are baby wipes and
cleaning materials kept? Where do you want me to put dirty diapers and soiled
disposable gloves?
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FA M I LY I N T E R V I E W F O R M
6. What are the routines for quiet time, bedtime and naps? When is bedtime? Do your children
have a favorite bedtime story? Do they like a light on? Do you prefer their door open or closed?
Do they sleep with particular blankets or stuff ed animals?
7. What do you want your children to wear for outdoor play? For naptime? For bedtime?
8. Where do I put dirty clothing?
9. Would you please show me any special equipment I might be using to take care of the
children?
10. Are there any medical conditions or medications that I should be aware of? If the child
is taking medication, where is it kept? Would you please fi ll out this Parental Consent
and Contact Form? Does your child have an AAP Emergency Information Form for
Children With Special Health Care Needs? Would you provide a copy that I can give to
EMS and/or hospital personnel in case of an emergency? Are there special instructions
or precautions I should be aware of?
Not e: If the parents do not fi ll out the Parental Consent and Contact Form you should
not give the children any medications.
11. Do your children have any other specifi c care needs or routines that I should know
about (e.g., tutoring, music or sports practice, faith practices)?
12. Do your pets need any special care?
13. Is there anything else I need to be aware of?
FA M I LY I N T E R V I E W F O R M
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