Form DCF-F-CFS0061 at a glance
What it is: Intake for Child Under 2 Years - Child Care Centers collects information about children under 2 years of age to aid child care workers in individualizing the program of care for the child.
Who signs: This form is to be completed by a parent / guardian and must be on file at the center prior to a child's first day of attendance.
This form is mandatory for certified providers to comply with 202.08(12)(g).
Failure to comply may result in issuance of a noncompliance statement.
This form is voluntary for licensed family and group child care centers; however, it meets the requirements of DCF 250.09(1)(c)1. and 251.09(1)(am).
A filled-in Form DCF-F-CFS0061 example: a parent fills out page 1 for a 14 month old
How to fill out Form DCF-F-CFS0061, box by box
Parent / child name and address
Enter the First Day of Attendance (mm/dd/yyyy). Under PARENT / CHILD NAME AND ADDRESS, enter Name - Child (Last, First, MI), Nickname (If any), Birthdate (mm/dd/yyyy), Name - Parent(s) (Last, First, MI), Telephone Number - Home and Address - Parent(s) (Street, City, State, Zip Code).
Health
Health conditions that may affect the care of the child must be recorded in the child's health history record. The form should be shared with any person who provides care for the child.
Child has frequent colds, ear infections, colic, etc. - Describe.
Meals
Under MEALS, enter the Current feeding schedule and the Length of time on current schedule.
Under Food type mark Breast milk, Formula, Strained, Junior or Table; for Milk type - Specify.
When eating, child is Held in lap, In highchair or Other - Specify.
Feeds self: Yes or No; If "Yes", uses: Spoon, Fork or Hands.
Special feeding problems: Yes or No; If "Yes" - Specify.
Food allergies: Yes or No; If "Yes" - Specify.
Enter Favorite foods - Specify and Refused foods - Specify.
Sleep
Under SLEEP, enter the Current sleep schedule and the Length of time on current schedule.
Falls asleep easily: Yes or No.
Describe the Mood upon awakening. Takes favorite toy(s) to bed - child over age 1 year: Yes or No; If "Yes" - list toy(s).
Sleep position - child under age 1 year Note: Children under age 1 year must be placed to sleep on their back unless a written statement from the child's physician is attached.
Sleep position for a child under age 1 year: Back or Side or stomach (physician statement attached). Sleep position for a child age 1 year and older: Back or Side or stomach.
Diapering / toileting
Under DIAPERING / TOILETING, mark Diaper type Cloth or Disposable. Diapers provided by parent: Yes or No.
Plastic pants used: Always, Never or Sometimes; If "Sometimes" - Specify.
Mark Yes or No for Highly sensitive skin.
Mark Yes or No for Frequent diaper rash.
Lotions, powders, or salves used: Yes or No; If "Yes", product name(s) - Specify.
Toilet training attempted: Yes or No; If "Yes", describe routine.
Type of toilet seat used at home: Potty chair, Special toilet seat or Regular toilet seat.
Regular bowel movements: Yes or No. Enter How often and Time(s) of day.
Toileting problems: Yes or No; If "Yes" - Describe.
Verbal communication
Under VERBAL COMMUNICATION, mark Family's spoken language: English, Spanish, Hmong or Other; If "Other" - Specify.
Enter the Age child began talking. Child speaks in Words or Sentences. Enter Words used to describe special needs - Specify.
Comforting
Under COMFORTING, Does child have a fussy time? Yes or No; If "Yes" - Specify time.
How is fussy time handled? Child likes to be: Held, Sung to, Rocked, Read to or Other - Specify. Special things you say or do to comfort child.
Self-expression
Under SELF-EXPRESSION, enter What causes your child to feel angry or frustrated? What frightens your child and how is it shown? How does your child express feelings of happiness, enjoyment, etc.?
Enter Additional comments.
Miscellaneous
Under MISCELLANEOUS, enter the Child's favorite indoor toys and activities - Specify. Child's favorite outdoor toys and activities - Specify.
By providing complete information about your child, you will be assisting staff in creating a positive experience for him / her while in care. List any information about your child's habits, abilities, or personality that you feel will be helpful to the staff while caring for your child.
Signature
SIGNATURE - Parent or Guardian, and Date Signed.
More rules for Form DCF-F-CFS0061
This form should be kept in the room where care is provided.
Regular updates can be noted.
If additional space is needed, attach a separate sheet.
Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04(1)(m), Wisconsin Statutes].
Sources
[1] Form DCF-F-CFS0061 (R. 03/2023), Intake for Child Under 2 Years - Child Care Centers, Department of Children and Families (the Official source link on this page).