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CLAY COUNTY SOCIAL SERVICES FAMILY DAY CARE INITIAL LICENSING EVALUATION-APPLICANT Provider’s 1. List the rooms in your home that will be used by day care children and the usable square footage for each. Bathrooms, closets, space occupied by major appliances and other space not used by children may not be counted as usable. Space occupied by adult furniture, if it is used by children may be counted as usable indoor space. (9502.0425 Subp. Square Rooms Footage Comments 2. Usable outdoor play space is feet. (9502.0425 Subp. 3. Is your yard fenced? (Not always required). (9502.0425 Subp. 4. Do all stairways with three or more steps have handrails? (9592,0425 Subp. 10A.) 5. Is the area between the handrails and the steps properly enclosed/protected? (9502.0425 Subp. 10B.) 6. Do you have secure gates or doors on your stairways? )9502.0425 Subp. 10C.) 7. Can your bathroom door be opened from the outside if locked? (9502.0425 Subp. 12B.) 8. Are all electrical outlets accessible to children under first grade covered or protected when not in use? (9502.0425 Subp. 18A.) 9. Are there any guns or firearms in the residence or on the property? If yes, where are they and the ammunition stored? (9502.0435 Subp. 10. What size/classification is your fire extinguisher (minimum 2A10BC)? Where is it located? Is it in working order? Do you know how to use it? (9502.0425 Subp. 16.) (Over) ---PAGE BREAK--- 11. Do you have smoke detectors installed on all levels in your home? Where are they located? Date tested Do they work? (9502.0425 Subp. 17.) 12. Are emergency phone numbers posted by the phone? Phone numbers of the local local fire department, police department, emergency transportation, (or 911), and Poison control are required. (9502.0435 Subp. 8B.) 13. Do you have a working flashlight in your home? (9502.0435 Subp. 8E.) 14. Do you have a battery-powered radio or TV? (9502.0435 Subp. 8E.) 15. What pets do you have? Date of last rabies Where are pet cages/litter boxes located? Are they cleaned away from food preparation, storage, or serving (9502.0435 Subp. 12C,D.) 16. Will you ever use a vehicle to transport day care children? If so, is the vehicle licensed according to State law? Does the driver of the vehicle have a current driver’s license? (9502.0435 Subp. 9C.) 17. Substitute caregiver(s) in the event of an emergency is/are: (9502.0405 Subp. 3L.) 18. Do you have a washable, non-absorbent surface for diapering? (9502.0435 Subp. 13D.) 19. How many infant seats do you have? How many high chairs do you have? (9502.0415 Subp. 5A.) Signature of Applicant Date