Family Interview Form Family Information and Emergency Numbers June 24th Today s date: Shah Family name: (555) 4343-0283 Home phone number: 119 George Street Address: kshah@email.com E-mail address: Jefferson Avenue Nearest cross street: (555) 012-8941 Phone number where parent can be reached during caregiving job: Child s name Age Weight Medicines Allergies Medical problems Ishan 10 91 lbs. - Quick relief inhaler as needed! - Daily-use inhaler. None Allergies Reva 8 67 lbs. None None None (555) 395-4928 Mobile phone number: Mrs. Ngo (555) 374-2395 Neighbor s name and phone number: Name and phone number of an adult who can make decisions if the parent cannot be reached: Leslie Chopra Aunt (555) 694-2741 9-1-1 Local emergency phone number: Dr. James Doctor s name: (555) 723-1224 Doctor s phone number: Jefferson Ave. Medical Center Name of preferred hospital to be used in an emergency: National Poison Control Center (PCC) hotline: (800) 222-1222 1 2014 Advanced Child Care Training
Household Rules and Discipline 1. What are the household rules? - No wrestling or rough play.! - No shouting inside.! 2. How would you like me to handle misbehavior? If the children are fighting, give them a chance to work it out on their own. If one of them is in danger of getting hurt, intervene and separate them. 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? They will both have homework on days after school. Make sure all homework is completed before they begin any play activities. Safety and Play 1. Would you take me on a tour of your house? Completed. 2. I would like to go over the Safety Inspection Checklist with you. Is that OK? Reviewed. 3. Does your family have a fire escape plan? If not, can you have one in place before I begin? Fire escape plan is posted on the refrigerator. 4. Do your children know what to do in a fire emergency? Ishan and Reva know to leave through the closest door when the smoke alarm goes off. NOTE: Families can find out more about how to be prepared for fires and other emergencies by contacting their local American Red Cross chapter or visiting 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? All of the alarms and fire extinguishers are up-to-date and working properly. The shut-off valve is in the hall closet. 2 2014 Advanced Child Care Training
6. Is it OK to take the children outside to play? Yes, but make sure they stay in the yard and out of the street. 7. Should I apply insect repellent or sunscreen to the children before they play outside? If so, what insect repellent or sunscreen should I use? Do any of the children have allergies or sensitivities to any of them? Have both kids use sunscreen and insect repellant before going outside. The preferred bottles will be on the kitchen table. Reapply sunscreen after swimming. 8. Do you have any pets that I need to care for? Are they friendly to strangers? Ishan has a goldfish, but I won t need to take care of it. 9. May I meet your children (and pets) before I care for them? I have known the children for 2 years. 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? Ishan and Reva are limited to one hour of recreational screen time per day. However, homework must be completed before this can happen. 11. What are your children s favorite toys and play activities? Ishan and Reva both like to build towers and cities with Ishan s Connect- Os. 12. Are there any play areas, toys or activities that are off-limits or restricted? Do not allow the children to play in our bedroom, the kitchen, or the bathrooms. 13. How do I work the door and window locks? Demonstrated during house tour. 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? Yes. Demonstrated during tour. The alarm company will automatically call Mr. Shah. I should call Mr. Shah to let him know it was an accident. 3 2014 Advanced Child Care Training
15. Where is your first aid kit kept? In the medicine cabinet in the bathroom. 16. Where is your emergency preparedness kit kept? In the hall closet. NOTE: Families can find out more about how to prepare for emergencies by contacting their local American Red Cross chapter or visiting redcross.org/disaster/masters. 17. Is there a spare house key for me to use? Yes. It will be left on the table. Basic Child Care 1. How do you want me to handle hand washing? Both children are old enough to wash their own hands. Make sure they do so after using the bathroom or playing outside. 2. How do you want me to handle brushing and flossing teeth? Both children are old enough to brush their own teeth. Make sure they do so before bed. 3. What can your children eat and drink? Do they have any food allergies? Neither of the children have any allergies. They can eat whatever food is in the refrigerator or pantry. 4. Will I be preparing any simple meals? I may need to make lunch for them. 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? Ishan and Reva will use the toilet when they need to. They can do this themselves. 4 2014 Advanced Child Care Training
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 stuffed animals? Both children go to bed at 9:00 p.m. They both read quietly before bed. Ishan likes his door closed, and Reva likes hers open. They both sleep with nightlights. 7. What do you want your children to wear for outdoor play? For naptime? For bedtime? They can wear normal clothes for outdoor play. They must wear bathing suits in the pool. Make sure they sleep in their pajamas. 8. Where do I put dirty clothing? Make sure Ishan and Reva put their dirty clothes in the hamper in the hall. 9. Would you please show me any special equipment I might be using to take care of the children? No special equipment. 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 fill 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? Ishan has asthma. If he has an asthma attack, please help him use his quick relief inhaler and call 9-1-1. NOTE: If the parents do not fill out the Parental Consent and Contact Form, you should not give the children any medications. 11. Do your children have any other specific care needs or routines that I should know about (e.g., tutoring, music or sports practice, faith practices)? No. 12. Do the children attend school or other activities outside of the home? What are the routines and schedules? Do I need to transport them? Ishan and Reva both attend Brookside Elementary School, but they ll be home by the time the job begins each day. 13. Do your pets need any special care? No pets. 5 2014 Advanced Child Care Training
14. Is there anything else I need to be aware of? Both kids are proficient swimmers, but they need to be supervised when in the pool. Horseplay is not allowed, and the pool gates must be closed at all times. Business Basics 1. What is the date and beginning and ending time of the job? 5:00 p.m. 10:00 p.m. on Mondays, Wednesdays and Thursdays, starting July 6th. 2. Should I answer the phone? If so, how should I do so? Answer the phone and take a message, if there is one. 3. Are there any rules I should observe in your home? May I use the TV, radio or computer? Once the children are asleep, I can watch TV. 4. May I make a short personal call? Am I allowed to do homework once the children are asleep? May I fix a snack? I can use the phone if I need to and help myself to food in the pantry. 14 5. I usually charge $ for my hourly rate. Is that OK? 6 2014 Advanced Child Care Training