Family Child Care Sample Forms Packet Page 8
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12Record of Observation
You must document any serious or unusual marks, bruises, injuries, behaviors or repetitive
occurrences such as a severe diaper rash that are observed on the child upon arrival at the child
care home or throughout the day.
Child's Name: ___________________________
Date observed:__________________________ Time observed: _____________________________
Observation:_______________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Were parents/guardians notified? Yes _________ No _________
How?_____________________________________________________________________________
__________________________________________________________________________________
Description of any noticeable changes in the behavior of the child:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Optional section:
Documentation of the parent’s/guardian’s comments to the educator:
__________________________________________________________________________________
Please remember that should you have reasonable cause to believe a child in your care is being abused
and/or neglected, you must report this to the Department of Children and Families at the Child at Risk
Hotline: 1-800-792-5200.
Page 8 of 12
FCCSampleFormPacket20100203
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