Emergency Information On Staff - Child Care Center printable pdf download

Revised 06/13

EMERGENCY INFORMATION ON STAFF

*This form can be used by Child Care Centers and Family Child Care Homes

NAME: _____________________________________________________________________________________________________________

ADDRESS: __________________________________________________________________________________________________________

NAME OF DOCTOR: ____________________________________________________ PHONE: ______________________________________

HOSPITAL PREFERENCE: _______________________________________________ PHONE: ______________________________________

LIST ANY CHRONIC MEDICAL CONDITIONS, INCLUDING MEDICATIONS TAKEN FOR THAT CONDITION, WHICH WOULD BE RELEVANT

IN AN EMERGENCY SITUATION: _______________________________________________________________________________________

___________________________________________________________________________________________________________________

EMERGENCY CONTACT PERSONS:

NAME: _________________________________________________________________ RELATIONSHIP ______________________________

ADDRESS: __________________________________________________________________________________________________________

HOME PHONE: _________________________________________ BUSINESS PHONE: ___________________________________________

NAME: _________________________________________________________________ RELATIONSHIP ______________________________

ADDRESS: __________________________________________________________________________________________________________

HOME PHONE: _________________________________________ BUSINESS PHONE: ___________________________________________

STAFF HEALTH QUESTIONNAIRE

IMPORTANT — Current health information must be completed annually by:

All staff (including the director). (2) All volunteers and substitutes prior to their coming into contact with the children.

NAME: _________________________________________________________________________________________________________

HOME ADDRESS: _______________________________________________________________________________________________

TELEPHONE NUMBER: ___________________________________________________________________________________________

I certify that I am emotionally and physically fit to care for children.

Signature: ______________________________________________________________ Date: __________________________________

This section of the form is for Child Care Center Director’s only

Director’s Statement:

I understand that I may request another evaluation of the employee’s emotional and physical fitness to care for children when there is

reason to believe that there has been deterioration in the employee’s emotional or physical fitness to care for children, as stated in Child

Care Rule 10A NCAC 09 .0701(b).

Signature: ______________________________________________________________ Date: _________________________________

Emergency Information On Staff - Child Care Center