Child Foster Care Home Safety Checklist - Department Of Human Services Page 2
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1
2Yes
No 6. Medication is not accessible to children. Schedule II controlled substances are stored in
N/A
a locked area.
(no Schedule II controlled substances in the home)
Yes
No 7. There is a safe water supply in the home.
Yes
No 8. The water temperature does not exceed 120 degrees Fahrenheit in order to prevent
scalding.
Yes
No 9. Weapons and ammunition are stored separately in locked areas that are not accessible or
N/A
visible to children. Weapons include firearms and other instruments or devices designed
for and capable of producing bodily harm.
(no weapons in the home)
__________________________________________________________________________________________
Sleeping Space for Foster Children & Reduction of Risk of Sudden Unexpected
Infant Death
Yes
No 1. The sleeping space for foster children has two exits. If the sleeping space for foster
children is in an area of the home not normally used for sleeping, describe the alternative sleeping arrangements:
__________________________________________________________________________________________
Check here if care WILL NOT be provided to infants
If checked, do not complete the items below.
Yes
No 2. A safe crib is available and used for each infant in care.
(must have prior to emergency
relative placement of an infant).
Yes
No 3. Infants younger than one year of age in care are placed to sleep on their back, in a crib,
directly on a firm mattress.
Yes
No 4. If an infant is not placed to sleep on their back, there is documentation from the infant’s
physician directing an alternative sleeping position for the infant. The physician directive
must be on a form approved by the commissioner.
Yes
No 5. The crib’s firm mattress has a fitted sheet, appropriate to the mattress size that fits tightly
on the mattress, and overlaps the underside of the mattress so it cannot be dislodged by
pulling on the corner of the sheet with reasonable effort.
Yes
No 6. Nothing is placed in the crib with the infant except for the infant’s pacifier.
Yes
No 7. Minnesota Statutes, section 245A.1435 Reduction of Risk of Sudden Unexpected
Infant Death in Licensed Programs has been reviewed by all caregivers. All
caregivers agree to comply with the requirements of this section.
Comments/explanation for obvious safety hazards or concerns
:
(use back of page if needed)
____________________________________________________________
____________________________________________________________
____________________________________________________________
______________________________________________________________
________________________
Applicant/License Holder
Date
______________________________________________________________
________________________
Agency Worker
Date
*Reference Minnesota Rules, part 2960.3050, subpart. 1. Items on this home safety checklist may not be deleted or
altered.
August 2017
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