Child Care Center & Preschools (2024)

Checklist of Items to be Submitted for Initial Licensure

This is a preliminary list of items that must be submitted and reviewed by the Department of Health and Human Services (HHS) for the initial license of a preschool or Child Care Center (CCC) found in Comm 204.

Licensing Regulation Checklist

ID# 470-3940

Criminal History Record Check Request Form

DCI-77 State of Iowa form

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To request national criminal history check from another center, use this form 470-4896.

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Required Written Policies and Procedures - Suggested Content

Written policies required by 441 Iowa Administrative Code Chapter 109.

Authorization for Release of Child and Dependent Adult Abuse Information

ID# 470-3301

Child Care Center Record Check Guide from DHS

HHS reviews use of forms DCI-77, 470-3301 and 470-2310

Fingerprinting Guidance

Iowa’s partnership with FieldPrint, the Livescan Fingerprinting Process

Waiver Agreement and Privacy Act Statement

DCI-45 State of Iowa form

Record Check Evaluation

ID# 470-2310

Provider Physical Exam Report

ID# 470-5152 (Acceptable physical examinations shall be documented on form 470-5152 per checklist 109.9(1)d.)

Child Abuse

Department of Health and Human Services (HHS) Report of Suspected Child Abuse - ID# 470-0665

Child Injury - Serious Incident Report Form

This form is required for reporting serious injury. For traditional injury documentation, this form is recommended per HHS Checklist 109.10(10)

Child Care Expense Statement for Foster Children

This document must be accurately completed and signed by the foster parent and child care provider for reimbursem*nt to occur to the foster parent after services have occurred and payment has been received.

Action Plan

This is a universal tool for the provider and consultant which is applicable to continuous quality improvement actions: i.e. Department of Health and Human Services (HHS) Referrals,Iowa Quality for Kids (IQ4K^®) Strategies, ChildNet Certifications or training key concepts.

Child Enrollment Information

Required information from HHS checklist, 109.9(2)a

Packet of required information to be kept in the children’s file for each child enrolled.

Child's File Checklist

Required information from Department of Health and Human Services (HHS) checklist, 109.9(2).

Checklist of required information to be included in each child's file.

Consent & Release

Required information from Department of Health and Human Services (HHS) checklist, 109.9(2)d and f.

Parent consent and release form addressing child pick up, trips, transportation, swimming, photos and other.

Dietary Modification Request Form

Required information for HHS Checklist, 109.15(3)a/Infant, 109.10(1)a/Preschool, 109.10(1)b/School-age.

If a participant needs to avoid specific foods for a medical reason, a prescribing licensed medial professional must document the diet modifications and sign this form.

Emergency Medical Treatment Authorization

Required information for HHS checklist, 109.9(2)b. This suggested form is being utilized from Comm 143.

Information should be readily accessible.

Emergency Practice Drills Record

Required information for HHS Checklist, 109.10(15)b.

Fire and tornado drills are practiced monthly and documentation kept on file for the current year and previous year.

Emergency Practice Drill Evaluation Tool

Required information for HHS checklist, 109.10(15)b.

Information should be readily accessible.

Employee, Volunteer Statement

Required information from Department of Health and Human Services (HHS) checklist, 109.6(7) and 109.9(1)a.

Signed statements regarding convictions, abuse, communicable diseases & controlled substances.

Equipment Check Form

Required information for HHS Checklist, 109.10(15)b.

Information should be readily accessible for equipment checks of smoke detectors, carbon monoxide detectors, fire extinguisher and evacuation equipment.

Health Form

Infant, Toddler, Preschool Age

Required information for HHS checklist, 109.10(1).

The provider should give this form to the parent/guardian of the attending child, to have the form completed by a physician. The provider should then keep a copy of this form in the child's personal file.

Health Form

School-age Child, Parent Statement of Health

Required information for HHS checklist, 109.10(1).

The provider should give to the parent/guardian of the attending child for completion. The provider should then keep a copy of this form in the child's personal file.

English Fillable Spanish

Healthy Child Care Iowa

Examples of forms and other available information on this site include:

Physical forms for all ages, breastfeeding support, child illness guide, diapering procedures, electrical outlet safety, exposure plan, first aid checklist, handwashing instructions, infant daily report, injury report, mandatory reporting site poster, sleep safe policy, etc.

Immunization Certificate - Provisional

When a Certificate of Immunization or Immunization Exempt Form are not available, a Provisional Certificate of Immunization can be used. Expiration date is usually 60 days. If the immunizations are further behind than can be caught up in 60 days, another provisional can be issued for an additional 60 days. As you can see on the record, a child must have received at least one dose of each of the required immunizations for this to be a valid option.

Immunization Exempt Form

Medical or Religious

Required information from Department of Health and Human Services (HHS) checklist, 109.10(1)c.

Form parents complete if they refuse to immunize their children because of religion or doctor recommendation.

Medication Record

Required information for HHS checklist, 110.8(3)C.

Form to be completed by the parent and provider when an enrolled child is given any medicine, topical cream, sunscreen, diaper ointment, breathing treatment, etc. Parent signature is required.

English Spanish

Playground Inspection

Required information from Department of Health and Human Services (HHS) checklist, 109.11(3)e.

Professional Development Record for Center Staff

Required information from Department of Health and Human Services (HHS) checklist, 109.7(2).

Safe Sleep ABC's

Required information from Department of Health and Human Services (HHS) checklist, 109.12(5)e.

Safe Sleep procedures for providers and parents.

Smoke Free Air Signs

Required information from Department of Health and Human Services (HHS) checklist, 109.10(11).

A direct link to the Iowa Department of Health Smoke Free Air Act information including a link to print signs.

Staff Files Checklist

(PDF & Word formats)

Required information from Department of Health and Human Services (HHS) checklist, 109.7(1).

Tracking form from Department of Health and Human Services (HHS).

Transporting Children

Weather Watch for Child Care