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2. Privacy Notice
   PLEASE NOTE: ANOKA COUNTY TAKES YOUR PRIVACY VERY SERIOUSLY. WE WILL TAKE EVERY AVAILABLE PRECAUTION TO MAINTAIN THE SECURITY AND INTEGRITY OF YOUR PRIVATE INFORMATION. PRECAUTIONS HAVE BEEN TAKEN TO MAKE ANOKA COUNTY’S WEBSITE AND E-MAIL SECURE, BUT ABSOLUTE SECURITY IS NOT GUARANTEED. IF YOU CHOOSE TO SUBMIT YOUR INFORMATION ELECTRONICALLY, YOU ASSUME ANY RISKS ASSOCIATED THEREWITH.
4. Notice:
   We are required to solicit evaluations from parents before each license renewal (MN Statute 9543.0040 Subp. 2B3b) and/or when a licensed provider is applying for a group family child care license. As a parent who is using or has used this home, we are hoping you will take this opportunity to answer the following questions. Feel free to include additional comments/explanations in the box below. The Minnesota Data Practices Act (MN Statutes 13) does not require you to provide the requested information in order to use licensed family child care. Information you do provide will be part of the agency’s assessment for the continued licensing of this home, and maintained in the agency licensing file regarding this provider. It may be shared with other staff in the state-wide welfare system whose jobs require access, and with staff in other agencies as provided by law. Information will be shared with the provider but not your identity.
   Note: If you provide information that indicates possible licensing violations, we are required to conduct an investigation.
6. Provider Name*
7. Today's Date
   Today's Date
9. Your First Name*
10. Your Last Name*
12. Your Mailing Address*
14. City*
15. State*
16. Zip*
18. Your Phone*
19. Your Email
21. Acknowlegment*

    I understand that if I have provided information that indicates possible licensing violations, Child Care Licensing may investigate it as a complaint.

    1. I understand
25. 1. Do you currently have a child(ren) enrolled in this home?

    1. Yes

    1. No
26. 2. Ages of child(ren)
28. 3. What contracted days/week and hours/day is your child(ren) in care?
30. 4. How long have you used/or did you use this home?
32. 5a. Is your provider's license posted?

    1. Yes

    1. No
33. 5b. How many children can she care for at any one time?
35. Please rate these questions using the following scale:
    5 – Strongly Agree
    4 – Agree
    3 – Neither Agree or Disagree
    2 – Disagree
    1 – Strongly Disagree
    N/A - Not Applicable
37. 6. Supports each child as an individual, providing focused and individual attention.

    1. 5
    2. 4
    3. 3
    4. 2
    5. 1
    6. N/A
39. 7. Provides a daily routine of recreational and learning activities for all age groups of children in care (i.e., story time, games, music, projects, exercise, creative play).

    1. 5
    2. 4
    3. 3
    4. 2
    5. 1
    6. N/A
41. 8. Provides an adequate supply of age-appropriate materials/activities, books, toys, and equipment.

    1. 5
    2. 4
    3. 3
    4. 2
    5. 1
    6. N/A
43. 9. I am satisfied with the condition of the toys and equipment used for the children.

    1. 5
    2. 4
    3. 3
    4. 2
    5. 1
    6. N/A
45. 10. Takes children outdoors on a daily basis (weather permitting).

    1. 5
    2. 4
    3. 3
    4. 2
    5. 1
    6. N/A
47. 11. Offers a variety of healthy meals and snacks.

    1. 5
    2. 4
    3. 3
    4. 2
    5. 1
49. 12. Supervises children at all times, both indoors and outdoors. (Within sight or hearing of infants, toddlers and preschoolers so that the caregiver is capable of intervening. For school age children the caregiver is available for assistance so that the child’s health and safety is protected).

    1. 5
    2. 4
    3. 3
    4. 2
    5. 1
    6. N/A
51. 13. Provides each child in care with their own clean, safe, comfortable sleep space (infants must sleep in an approved crib or port-a-crib, toddlers/preschoolers are provided with a mat, crib, cot, bed, sofa, blanket or sleeping bag for nap/quiet time).

    1. 5
    2. 4
    3. 3
    4. 2
    5. 1
    6. N/A
53. 14. Guides behavior in a constructive, age-appropriate manner through intervention, guidance, and redirection.

    1. 5
    2. 4
    3. 3
    4. 2
    5. 1
    6. N/A
55. 15. Is able to adequately care for the number and age distribution of the children in her care.

    1. 5
    2. 4
    3. 3
    4. 2
    5. 1
    6. N/A
57. 16. The facility:
59. Has adequate play/nap space for children.

    1. 5
    2. 4
    3. 3
    4. 2
    5. 1
    6. N/A
61. Meets my safety/cleanliness expectations.

    1. 5
    2. 4
    3. 3
    4. 2
    5. 1
    6. N/A
63. Outdoor play area appears safe/adequately equipped and free from hazards.

    1. 5
    2. 4
    3. 3
    4. 2
    5. 1
    6. N/A
65. 17. I am satisfied with the diaper changing area, process and frequency.

    1. 5
    2. 4
    3. 3
    4. 2
    5. 1
    6. N/A
67. 18. I am satisfied with the communication with the provider.

    1. 5
    2. 4
    3. 3
    4. 2
    5. 1
    6. N/A
69. 19. I am satisfied with the overall quality, consistency, and stability of care provided.

    1. 5
    2. 4
    3. 3
    4. 2
    5. 1
    6. N/A
71. 20. I am satisfied with the overall environment, safety, and hygiene practices of my provider.

    1. 5
    2. 4
    3. 3
    4. 2
    5. 1
    6. N/A
73. 21. If you are no longer using this home, what was the main reason you left?
75. 22. Describe the provider’s strong points and/or assets in the care they provide.
77. 23. Do you have any concerns regarding the physical or emotional health and well-being of your provider that impacts his/her ability to care for children?
79. 24. Are there any areas you feel could be improved or enhanced?
81. Additional comments (is there anything else you would like our agency to be aware of regarding this provider or the home?)
83. Thank You for completing this evaluation.
    If you would like to talk directly with a licensor in our agency about this provider, please call 763-324-1235.
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87. 1. Receive an email copy of this form.
88. Email address

    This field is not part of the form submission.

89. Submit

* indicates a required field