Score Sheet Rating Form – Fill Out and Use This PDF

Observer: ___________________________________

Observer Code: ___ ___ ___

Date of Observation: __ __ / __ __ / __ __

Center/School: _______________________________

Center Code: ___ ___ ___

m m

d d

y

y

Number of children with identified disabilities: ___ ___

Room: ______________________________________

Room Code: ___ ___

Check type(s) of disability: □ physical/sensory

□ cognitive/language

Teacher(s): ___________________________________ Teacher Code: ___ ___

□ social/emotional

□ other:___________________

Birthdates of children enrolled: youngest

__ __ / __ __ / __ __

Number of staff present: ___ ___

m

m

d

d

y

y

oldest

__ __ / __ __ / __ __

Number of children enrolled in class: ___ ___

m

m

d

d

y

y

□ AM

□ PM

Highest number center allows in class at one time: ___ ___

Time observation began: ___ ___ : ___ ___

□ AM

□ PM

Highest number of children present during observation: ___ ___

Time observation ended: ___ ___ : ___ ___

Time interview began: ___ ___ : ___ ___

□ AM

□ PM

Time interview ended: ___ ___ : ___ ___

□ AM

□ PM

SPACE AND FURNISHINGS

1. Indoor space

1

2

3

4

5

6

7

Notes:

3.5/5.3 accessibility:

Y N

Y N NA

Y N

Y N

1.1

3.1

5.1

7.1

1.2

3.2

5.2

7.2

1.3

3.3

5.3

7.3

1.4

3.4

3.5

2. Furniture for routine

1

2

3

4

5

6

7

5.2, 7.2 Child-sized table(s) and chairs? ________________________

care and play

Y N

Y N

Y N NA

Y N NA

1.1

3.1

5.1

7.1

1.2

3.2

5.2

7.2

1.3

3.3

5.3

7.3

3.4

5.4

7.4

5.5

7. Meals/snacks

Notes:

1

2

3

4

5

6

7

1.3, 3.3, 5.3 Same sink used? {y / n}

1.3, 3.3, 5.3 Handwashing: (√=yes, χ=no)

Y N NA

Y N NA

Y N NA

Y

N

Children

Adults

Sink sanitized? {y / n}

Before

Before food

1.1

3.1

5.1

7.1

eating

prep, feeding

1.2

3.2

5.2

7.2

Tables/highchair tray washed,

After

After feeding

1.3

3.3

5.3

sanitized? ___________________

eating

1.4

3.4

5.4

1.5

3.5

5.5

8. Nap

1

2

3

4

5

6

7

NA

1.1 All cots/ mats, cribs

36” apart or solid barrier? {y / n}

Y N

Y N

Y N NA

Y N

1.1

3.1

5.1

7.1

Other issues:

1.2

3.2

5.2

7.2

1.3

3.3

5.3

3.4

9. Diapering/toileting

1

2

3

4

5

6

7

1.1, 3.1 Diapering procedure (every adult observed): (√=yes, χ=no)

Other issues:

Prep

1.1, 3.1 Same sink sanitized? (y/n)

Y N

Y N

Y N

Y N NA

Proper disposal

1.3, 3.3 Handwashing

1.1

3.1

5.1

7.1

Wipe child’s hands

Adult

1.2

3.2

5.2

7.2

Wipe adult’s hands

1.3

3.3

5.3

7.3

Child

Sanitize diap. area

1.4

3.4

5.4

Same sink sanitized

10. Health practices

1

2

3

4

5

6

7

1.1, 3.2, 5.2

Handwashing observations: (√=yes, χ=no)

Child

Adult

Y N

Y N NA

Y N NA

Y N NA

Upon arrival in class or re-entry from outside

1.1

3.1

5.1

7.1

Before water; after sand, water, messy play

1.2

3.2

5.2

7.2

After dealing w/ bodily fluids

1.3

3.3

5.3

7.3

After touching pets or contaminated objects

3.4

5.4

11. Safety practices

1.1, 1.2, 3.1, 5.1 Safety hazards:

1

2

3

4

5

6

7

Y N

Y N

Y N

Y N

Major

Minor

1.1

3.1

5.1

7.1

Indoor:

1.2

3.2

5.2

7.2

1.3

3.3

Outdoor:

A. Subscale (Items 6 - 11) Score __ __

B. Number of items scored __ __

PERSONAL CARE ROUTINES Average Score (A ÷B) __.__ __