Family Child Care Home Questionnaire

Here at Options for Working Families, our goal is to provide you with the best opportunity to receive frequent client referrals. We rely upon up-to-date information about your Child Care Program. Please take a few moments to fill in the information below, to ensure that we are providing accurate information to our clients. Please send a copy of your DCYF license. If your program is accredited or if you have a CDA Credential, please enclose a copy of those certificate(s) as well.

*First Name

* Last Name

Business Name

* Street Address

* City

* State

* Zip

*Have you ever had to expel a child for any reason?
Yes
No
Mailing address (if different from street address)

Street

City

State

Zip

* Home Phone Number

Fax number

Email address

Cell Phone Number

*DCYF Expiration Date

* How many openings do you have?

* Child care age range

What schools are near your home?

*

What applies to your Child Care Program?

Transportation Provided
Walking Distance to School
Near Public Transportation
On School Bus Route
Bus Stop in front of home
No Transportation
*Language or Languages spoken in Family Child Care Home
English
Spanish
Portuguese
Russian
Hmong
French
Laos
Cambodian
Other Languages Spoken

*The hours that childcare program is open

Shift 1 (i.e. 9am - 5pm)

Shift 2 (i.e. 9am - 5pm)

Shift 3 (i.e. 9am - 5pm)

* Days your Family Child Care Home is open
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
* What applies to your Family Child Care Home?
Full year
School year only
Summer only
Before School Care
After School Care
Drop In
Full Time Care
Part Time Care
Both
Temporary or Emergency Care
Rotating Schedule Care
Open Major Holidays
Open Minor Holidays
Infant/Toddler Rate

Weekly FT

Weekly PT

Hourly FT

Hourly PT

Daily FT

Daily PT

Preschool Rate

Weekly FT


Weekly PT

Hourly FT

Hourly PT

Daily FT

Daily PT

School Age Rate

Weekly FT

Weekly PT

Hourly FT

Hourly PT

Daily FT

Daily PT

* Will discuss rates with parents?
Yes
No
Additional Fees
Extended Day
Application Fee
Late Payment Fee
Supply Fees
*Accept the DHS Subsidy
Yes
No
My Provider ID (CCAP Enrollment ID)

Date of your last DCYF home visit

*Environment

Is there any smoking in the home?
Yes
No
* Are there any pets in the home?
Yes
No
* Is there a pool in/out of the home?
Yes
No
* Meals Provided
Breakfast
Morning Snack
Lunch
Afternoon Snack
Dinner
USDA Food Program
Special Meal Request
Do Not Provide Meals/Parents Responsibility
Philosophy
Montessori
Religious
Waldorf
Other
* Policies
Child Absence Allowance (no charge when child absence for period of time)
Multi-child Discount
Provider Sick Allowance (Require # of allowable paid sick days for provider)
Provider Vacation allowance (Require Payment during provider vacation)
Provides daily written family reports
Provide verbal reports to parents
Written Parent/Provider contract
None
Other Policies

Special Skills
Sign Language
Special Needs Experience
Works with EI (Early Intervention)
Other Special Skills

* Safety
CPR Current Within 2yrs
First Aid Training
Health-Related Degree
On-Site Nurse
On-Call Nurse
Liability Insurance
Special Needs (What kinds of special needs do you have experience with?)
Developmental Disabilities
Medical Tech.
Autism Spectrum
Behavioral Health
Physical Disabilities

Do you accept pending certificate numbers from families that are receiving child care subsidy?

Other special needs

* Training ( Required Amount of Training to maintain license)
Less than 12 hours
13-40 hours
40 or more
Credit-based training
Heads Up Reading Program
Rhode Island Early Learning Standards
CDA
* Experience
Under 1 year Experience
1-3 years
4-9 years
10-20 years
21+years
Family child Care Experience
Child Care Center Experience
Parenting
*Education
High School Education/GED
Some College, child related
Some college, other emphasis
Associate Degree, child related
Associate Degree, other
Bachelors, child related
Bachelors, other
Master's Child related
Master's Other emphasis
Doctrine
Did not graduate High School
*NAFCC (Family) Accreditation
Yes
No
Quality Indicators
Bi-Lingual Curriculum
Comprehensive Services ( Provider must be enrolled in the Comprehensive Services program)
DAP/planned written curriculum ( Developmentally Appropriate)
Parent/Child Playgroup
Therapeutic Child Care (Specialized services for children and youth with special needs-specifically trained)
Written plan for family involvement
Business Practices
Maintains financial/records
Parent Handbook
Post Licensing Conditions/Age ratios
Written Program Policies
Other
Member Affiliation
FCCH (Family child Care Homes of RI)
NAEYC membership (Centers/Family)
NAFCC membership (FCC)
RIEAYC (Rhode Island Education Association of Young Children)
Other Member Affiliation

Family Care Setting
House
Apartment
Townhouse
Mobile Home
Duplex
Non-residential
Fenced Yard
* Do you have a military discount?
Yes
No




Fields marked with an asteris  (*) are required