Minimum Standards

for Tribal Child Care

***A Health and Safety Guide***

**Table of Contents**

Introduction 1

Section I: Policies/Practices/Caregiver Training 2

Staffing Ratios and Group Sizes 2

Caregiver Qualifications 3

Caregiver Training 3

Program Policies 4

Section II: Building and Premises 5

Safe Environment 5-7

Nurturing and Enriching Environment 8

Transportation 9

Section III: Infection Control 10

Immunization 10

Sanitation 11-12

Handwashing 12

Food Safety 13-14

Care of Ill Children 15

Caregiver Health 16

Appendix: Standard Precautions 17-18

Resource List 19-21

**INTRODUCTION**

The Personal Responsibility and Work Opportunity Reconciliation Act of
1996 (Public Law 104-193) requires that in lieu of any licensing and
regulatory requirements applicable under State and local law, the U.S.
Department of Health and Human Services shall develop minimum child care
standards for Indian Tribes and Tribal Organizations receiving funds
under the Child Care and Development Fund (CCDF). The law requires that
the standards be developed in consultation with Indian Tribes and Tribal
Organizations and appropriately reflect tribal needs and available
resources.

The Minimum Tribal Child Care Standards were first published in April
2000 after three years of consultation with Tribes, tribal
organizations, and tribal child care programs. To oversee the
development of the standards, the Child Care Bureau, U.S. Department of
Health and Human Services, convened the Tribal Child Care Standards
Advisory Committee that included representatives from tribal child care
programs, the Child Care Bureau, the Indian Health Service, the Maternal
and Child Health Bureau, the Head Start Bureau (American Indian Programs
Branch), the American Academy of Pediatrics, and other health and child
care organizations. In addition, the Child Care Bureau has undertaken
several activities to inform and consult with Tribal Leaders, including
holding consultative sessions with Tribal Leaders and tribal CCDF
programs at ACF's annual American Indian/Alaska Native Child Care
Conferences.

The Child Care Bureau is reissuing the minimum standards as a \"Health
and Safety Guide\" for CCDF Tribal Lead Agencies in conjunction with the
2005 Tribal Cluster Trainings, \"Supporting the Physical, Social, and
Emotional Wellness of Our Tribal Children.\" These voluntary guidelines
represent the baseline from which all programs should operate to ensure
that children are cared for in healthy and safe environments and that
their basic needs are being met. Many Tribes may currently be exceeding
the standards set forth in this document; others may want to use these
standards as the starting point for developing their own tribal child
care standards.

All CCDF Tribal Lead Agencies should note that these guidelines express
minimum standards for health and safety in child care and are not
intended to supersede any existing federal, state, tribal, or local laws
or regulations. Tribal CCDF programs are responsible for knowing the
laws and regulations that govern them and the child care programs that
they fund through CCDF and for incorporating these laws and regulations
into their tribal child care policies, procedures, and standards, as
appropriate.

**SECTION I**

**POLICIES/PRACTICES/**

**CAREGIVER TRAINING**

**STAFFING RATIOS AND GROUP SIZES**

**Principle**

*Adequate staffing ratios are important for providing quality care to
children and retaining staff.*

**Why This Is Important**

-   Lower ratios allow for direct supervision and consistent caregiving.

-   Children benefit from interaction in smaller groups.

-   Smaller groups and lower ratios reduce stress on individual
    caregivers.

-   Close supervision ensures the physical safety of the children and
    allows for better maintenance of sanitation routines.

-   It is important for children to build long-term, trusting
    relationships with caregivers. Having a small number of caregivers
    contributes to forming these relationships.

**Standards**

-   Caregivers should meet or exceed state standards for
    child-to-caregiver ratios and group sizes.

-   Caregivers should directly supervise infants, toddlers, and
    preschool children by sight or hearing at all times, even when the
    children are in sleeping areas.

> **NOTE:** In child care centers, caregivers should directly supervise
> infants, toddlers, and preschool children by sight **AND** sound at
> all times, even when the children are in sleeping areas.

-   Caregivers should know the whereabouts of the children in their care
    at all times.

**CAREGIVER QUALIFICATIONS**

**Principle**

*Children must be cared for and directly supervised by responsible,
caring individuals.*

**Why This Is Important**

-   Children need to receive the highest quality of care available.

-   Children thrive emotionally, physically, and developmentally in a
    high quality, nurturing child care environment.

**Standards**

-   Tribes should have a policy for conducting employment and character
    references on each individual who has contact or control over
    children in child care settings.

-   Tribal child care programs should have a policy for conducting
    background checks consistent with appropriate federal, state, and
    tribal laws and regulations and should coordinate their background
    check policy with other tribal agencies.

**CAREGIVER TRAINING**

**Principle**

*Well-trained caregivers can provide a healthy and high-quality
environment for the children and for themselves.*

**Why This Is Important**

-   Caregivers play an important role in the development of young
    children and should have all the tools necessary to provide children
    with optimal care.

-   Training ensures caregivers have access to current knowledge and
    techniques.

-   Training can be an opportunity for professional development and
    networking with other child care providers.

-   Joint training with members of the community (physicians or fire
    safety officials, for example) can expand the level and quality of
    care for children.

-   Child care providers can support families as partners in the child's
    education and care.

**Standards**

-   The Tribe should have a written plan to ensure the training of
    caregivers in areas including, but not limited to: health and
    safety, child development, prevention and control of infectious
    diseases (including Standard Precautions), child abuse prevention
    and reporting, first aid/first response, and choking prevention.

-   Caregiver training should be documented.

**PROGRAM POLICIES**

**Principle**

*Established child care health and safety policies, including policies
for emergency situations, ensure the safety and well being of all
persons in the child care setting.*

**Why This Is Important**

-   Pre-established policies reduce confusion during emergencies.

-   Written policies assure parents of the quality of care their child
    should receive and reduce misunderstandings between the child care
    providers and family members.

-   Prevention strategies can help improve caregiver job satisfaction
    and morale, and reduce the number and seriousness of injuries and
    illnesses.

**Standards**

-   Written policies should be established, implemented, maintained, and
    available, and should address, but not be limited to, the following
    content areas: child development, health and safety, prevention and
    control of infectious diseases, child abuse prevention and
    reporting, first aid/first response, and management of blocked
    airway (CPR).

-   Policies related to program operation should be shared with parents
    of children in care.

-   All caregivers, other staff, and volunteers should be trained in the
    importance and implementation of the policies.

-   If children will be transported, drivers should be licensed and
    children should be fastened in the vehicle in an age-appropriate
    restraint that is properly positioned and installed. Appropriate
    child passenger restraints should be utilized when any mode of
    transportation is used.

-   To reduce the risk of Sudden Infant Death Syndrome (SIDS), infants
    should be placed to sleep on their backs unless otherwise directed
    by the child's physician, and all sleeping arrangements for infants
    under 12 months of age should use firm mattresses and avoid soft
    bedding materials such as comforters, pillows, fluffy blankets, or
    stuffed toys.

-   The caregiver should ask parents for information regarding the
    child's development, health, and behavioral status, especially
    information about the child's health since the last attendance in
    the facility. The child's cultural background should be respected in
    all aspects of the program.

-   When bottle feeding, caregivers should hold infants. Infants who are
    unable to sit should always be held for bottle feeding. The
    caregiver should not permit bottle propping or infants carrying
    bottles throughout the day or night.

-   Children should not be physically restrained by bonds, ties, or
    straps for disciplinary purposes. If a child must be restrained for
    medical reasons, that restraint should occur in accordance with the
    instruction of the child's physician and/or practitioner and
    permission of the parent. The use of manufacturer installed safety
    straps on infant and toddler equipment is permissible.

-   Each caregiver should have and implement a written discipline policy
    that outlines positive methods of guidance appropriate to the ages
    of the children.

**SECTION II**

**BUILDING AND PREMISES**

**SAFE ENVIRONMENT**

**Principle**

*Healthy children require a safe physical environment in which to eat,
sleep, and play.*

**Why This Is Important**

-   A well-designed environment within a clean and well-maintained
    facility supports each child's physical, cognitive, emotional, and
    social development.

-   Proper attention to the issues of safety and sanitation protects the
    health of children and caregivers and prevents injuries.

**Standards**

**The building interior and exterior should be maintained as follows:**

-   Guidelines should be developed to assure child care settings are
    safe, and meet tribal, state, or local fire and safety regulations.

-   The caregiver should follow tribal, state, or local guidelines
    regarding the installation and appropriate use of smoke detectors.

-   Smoke detectors and other devices should meet the tribal, state, or
    local standards.

-   Usable space, equipment, and exit arrangements should be adequate
    for the number, ages, and abilities of the children.

-   Indoor and outdoor play areas should be checked for hazards daily
    and prior to their use by children.

-   Paint on both interior and exterior premises should be free from
    hazardous quantities of lead. It is recommended that tribal programs
    seek assistance in assessing lead paint levels by contacting the
    Indian Health Service, tribal sanitarian, or local lead paint
    assessor who is certified by the Environmental Protection Agency.

-   A plan should be in place to ensure routine maintenance, and
    sanitation procedures should be followed to keep the building clean,
    sound, and in good repair.

-   Sufficient heating and cooling should be provided within the
    facility to maintain a temperature that will not cause harm to the
    children.

-   Ventilation should be provided to prevent the accumulation of
    harmful odors and fumes.

**Access and exposure to hazardous materials should be prevented as
follows:**

-   Poisons, toxic materials, cleaning supplies, sharp or pointed
    objects, plastic bags, matches, flammable liquids, drugs of any
    kind, insecticides, and other hazardous materials should be
    inaccessible to children at all times. Hazardous materials should be
    properly stored in labeled containers which, if appropriate, should
    be locked.

-   Guns should be equipped with child protective devices and kept under
    lock and key and separate from ammunition.

-   Ponds, pools, stock tanks, or permanently standing water should be
    enclosed with a fence, or otherwise safeguarded to ensure that they
    can not be accessed by children. When children are engaged in water
    play activities, constant supervision should be required.

-   Electrical outlets accessible to children should be covered with
    child resistant safety plugs.

-   Smoking, alcohol, and illegal drugs should be prohibited on the
    premises when children are present. Alcohol, tobacco products, and
    drugs of any kind should be inaccessible to children at all times.

> NOTE: In child care centers, smoking, alcohol, and illegal drugs
> should be prohibited on the premises AT ALL TIMES.

-   Persons under the influence of alcohol or illegal drugs should not
    be allowed in the child care setting.

**In the event of an emergency, children and caregivers should be
protected as follows:**

-   The child care facility should have emergency plans and procedures
    in place that are appropriate for the child care setting, addressing
    potential disasters such as fire, hurricane, volcano, flood,
    blizzard, tornado, etc. These plans and procedures, excluding
    child-specific information, should be prominently posted in public
    areas of the facility.

-   Emergency plans should include:

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-   A record of two emergency contact persons for each child;

-   Permission slips for emergency transport to health care facilities
    for the provision of emergency care, signed by parents or legal
    guardians;

-   Permission for emergency treatment;

-   A hospital and physician of choice as designated by the parent or
    guardian; and

-   Individual plans for children with special health care needs,
    including allergies, developed by that child's physician.

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-   Telephones or another identified and acceptable means of
    communication should be available to facilitate contact with
    emergency services.

-   The child care setting should have a minimum of two unobstructed
    exits leading to safe, open areas.

-   Emergency evacuation procedures should be in place and posted
    prominently within the child care setting. Evacuating children
    should be the first priority in the event of a fire or other
    emergency.

-   Approved, properly maintained, multi-purpose fire extinguishers,
    appropriate for the size of the child care setting, should be
    readily available, and caregivers should be trained on their
    operation.

-   An appropriately stocked first aid kit should be present and easily
    accessible to caregivers at all times, including during field trips
    and while transporting children. At a minimum, it should include:
    emergency plans, disposable gloves, band-aids and bandages, tape,
    sterile gauze pads, roll gauze, scissors, emergency numbers, first
    aid resource guide, and an insect sting kit.

**Equipment should be maintained to reduce the possibility of injury as
follows:**

-   Materials, toys, and furnishings should be safe, age appropriate,
    durable, and maintained in good condition.

-   The layout and maintenance of all indoor and outdoor equipment and
    surfaces should be carefully selected to minimize the possibility of
    injury to children.

-   Equipment should be stored in a safe and orderly fashion when not in
    use.

-   Infant and toddler toys should be made of non-toxic materials and
    should be cleaned and/or sanitized at least daily. When soiled, they
    should be removed from use until they have been cleaned and
    sanitized. If the toys are not used, they should be cleaned weekly.

-   Cribs, cradle boards, and/or infant sleep equipment should keep the
    infant safe from the dangers of suffocation, and should not allow a
    child to either fall, become entrapped, or have clothing tangled on
    protrusions.

-   No child should sleep on a bare, uncovered surface. Seasonally
    appropriate covering, such as sheets or blankets that are sufficient
    to maintain adequate warmth, should be available and should be used
    by each child below school age. Sleeping arrangements for infants
    under 12 months of age should follow SIDS prevention strategies as
    outlined on page 4.

-   Children should not share bedding. Related children may share
    sleeping arrangements with parental approval. Each item of sleep
    equipment (sheets, blankets, pillows, etc.) should be assigned to an
    individual child and should be used only by that child while he/she
    is enrolled in the child care program. Each mat, cot, or crib
    mattress should be covered with the child's individual sheet for
    exclusive use by that child.

**NURTURING AND**

**ENRICHING ENVIRONMENT**

**Principle**

*A nurturing and enriching child care environment stimulates learning
across all domains of a child's development: social, emotional,
cognitive, and physical.*

**Why This Is Important**

-   The quality of a child's surroundings can have a significant effect
    on his or her happiness and emotional well-being.

-   Children who are encouraged to respect the feelings and rights of
    others engage in positive relationships that build social
    competence.

-   Healthy child development and brain growth requires human contact as
    well as interesting and stimulating surroundings.

**Standards**

-   A written plan for daily activities should be in place. The daily
    plan should include the goals for children's development and
    learning and the activities through which they will achieve these
    goals.

-   Daily routines should be established to allow children to develop
    expectations and feel secure at the child care setting.

-   Caregivers should model respect for the feelings and rights of
    others, and provide an environment that respects gender, culture,
    ethnicity, family composition, and the special emotional, cognitive
    and developmental needs of the individual child.

-   The child care setting should include toys, activities, and
    materials that are safe and appropriate for the various
    developmental stages of the children in care.

-   All equipment in the setting should be designed to support the
    abilities and developmental levels of the children served, with
    adaptations made as necessary to support children with disabilities.

**TRANSPORTATION**

**Principle**

*Children should always be transported in a safe manner.*

**Why This Is Important**

-   Motor vehicle accidents are the leading cause of death for children
    in the United States.

**Standards**

-   If children are transported, a written permission slip signed by a
    parent or recognized guardian should be on file.

-   Children should be required to use safety belts or, for children
    under age 4, federally approved and properly installed child
    passenger restraint systems (car seats) or other appropriate child
    passenger safety seats appropriate for the mode of transportation.

-   Children should never be transported in the rear of a pick-up truck.

-   The National Highway Traffic Safety Administration (NHTSA)
    recommends placing all children 12 and under in the rear seat. In
    the event that no option exists for placing a child in the rear
    seat, the following steps should be taken:

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-   Properly restrain the child.

-   Push vehicle seat all the way back to maximize distance between
    child and air bag.

-   Seat child directly against the seat back.

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-   Children should never be left unattended in vehicles.

-   Only licensed drivers should be allowed to transport children.

-   Appropriate child-to-caregiver ratios should be maintained during
    the transportation of children.

-   Strict policies should be developed to prevent persons under the
    influence of alcohol or illegal drugs from operating vehicles while
    transporting children.

-   Automobile insurance should be maintained to meet or exceed minimum
    state standards.

-   Vehicles should be routinely inspected and maintained to ensure that
    all safety features are operational.

-   There should be no smoking in vehicles when transporting children.

**SECTION III**

**INFECTION CONTROL**

**IMMUNIZATIONS**

**Principle**

*Immunizations prevent the spread of disease.*

**Why This Is Important**

-   Diseases may spread quickly in all child care settings.

-   Young children may be more vulnerable to certain vaccine-preventable
    diseases.

-   Child care can provide a service by identifying children who need
    immunizations and referring them to available health care resources.

-   Since public school attendance requires immunizations, it is
    important for young children to receive required immunizations,
    appropriate health examinations, and other health services in the
    early years of life.

**Standards**

-   Children receiving care should be age-appropriately immunized in
    accordance with Indian Health Service (IHS) or State public health
    agency recommendations.

-   Tribes may exempt:

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-   Children whose parents or guardians object to immunization on
    religious grounds, and/or

-   Children whose medical condition requires that immunizations not be
    given.

**SANITATION**

**Principle**

*Proper sanitation practices significantly reduce the spread of
disease.*

**Why This Is Important**

-   Germs can be spread in the child care setting, toilet areas, and on
    toys.

-   Practicing good personal and environmental hygiene reduces the
    incidence of infectious diseases.

-   Diapering and the disposal of solid waste in the child care setting
    create the risk of infection and need to be managed safely.

**Standards**

-   General sanitation equipment should be kept clean, sanitary, and in
    operable condition.

-   Any surface contaminated by body fluids (saliva, mucus, vomit,
    urine, stools, or blood) should be cleaned and disinfected
    immediately, and caregivers should use Standard Precautions (see
    Appendix), including the wearing of gloves, when cleaning
    contaminated areas.

-   Toilet areas, including sinks, countertops, faucets, handles,
    doorknobs, toilet bowls, and toilet seats, should be cleaned daily.
    These areas should be cleaned immediately when soiled.

-   Potty chairs and changing tables should be cleaned and disinfected
    after each use.

-   Floors should be cleaned daily; when soiled, they should be cleaned
    immediately. Carpets and rugs should be shampooed when soiled and
    vacuumed at least daily.

-   Toys should be cleaned weekly; when soiled, they should be cleaned
    immediately. Small toys that children can place in their mouths
    should be cleaned and disinfected after each use.

-   Garbage and rubbish should be removed from rooms where children and
    adults will be present.

-   Garbage and rubbish should be stored in closed containers that
    prevent access by children, insects, and rodents and other animals.

**Food Service Sanitation**

-   Food preparation areas should be separate from play, toilet,
    bathroom, and diaper changing areas, and areas where animals are
    kept.

> NOTE: In child care centers, food preparation areas should be separate
> from eating areas as well.

-   Food preparation areas, including countertops and tabletops, should
    be cleaned and disinfected before and after each use.

-   Dishes, highchair trays, and food service utensils should be cleaned
    and disinfected after each use. Dishes and food service utensils
    should be cleaned in separate wash basins from those used to clean
    up after diaper changing.

-   Dishes and food service utensils should be allowed to air dry and
    stored in a manner that preserves their clean/disinfected status.

**HANDWASHING**

**Principle**

*Proper handwashing routines are a regular part of every quality child
care program's health promotion and disease prevention strategy.*

**Why This Is Important**

-   • Thorough handwashing is one of the most important and effective
    means for preventing disease transmission.

**Standards**

-   All caregivers, volunteers, and children should wash all parts of
    their hands for at least 10 seconds with soap and water and then
    rinse them with water. If standing water is used to rinse hands, the
    water should be fresh for each person and should not be re-used.
    Running water is preferable.

-   All caregivers, volunteers, and children should wash their hands:

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-   Before and after eating, giving medication, and participation in
    moist play;

-   After diapering, toileting, cleaning, and the handling of body
    fluids, even if gloves are used;

-   After handling animals, animal waste, or animal cages.

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-   A clean, individual paper or cloth towel should be used for each
    child within the child care setting.

> NOTE: In child care centers, paper towels should be used to dry hands
> and turn off faucet handles. Additionally, in child care centers,
> signs should be posted at each sink indicating when handwashing is
> required and the proper steps to follow.

-   Each paper towel should be used once by only one individual.

**FOOD SAFETY**

**Principle**

*Food should be stored, prepared, and served in a manner that prevents
the spread of disease.*

**Why This Is Important**

-   Improperly stored food can spoil and/or lead to rodent and insect
    contamination.

-   Poor food preparation practices can lead to contamination and
    disease.

**Standards**

**Drinking Water**

-   Safe drinking water should be accessible to children while indoors
    or outdoors.

-   Drinking water should be dispensed by personal water bottle,
    drinking fountain, or cups labeled for individual use by each child.

**Food Handling**

-   Food should be properly wrapped and handled.

-   Foods brought from home should be labeled with the child's name,
    date, and the type of food, and should not be shared with other
    children unless intended for that purpose.

-   Warm food should be maintained at a temperature not less than 140ºF.

-   Cold foods should be properly refrigerated, maintained at a
    temperature of 40ºF or lower in the refrigerator and 0ºF or lower in
    the freezer.

-   Food that has been served on the child's plate and not eaten should
    be discarded in containers with tight fitting lids that are emptied
    at least daily.

**Bottle Feeding and Breastfeeding**

-   Breastmilk (if not frozen) and prepared bottles of formula should be
    kept refrigerated until immediately before use.

-   Frozen breastmilk should be thawed under cold running water or in
    the refrigerator.

-   When there is more than one bottle-fed infant, bottles of breastmilk
    and formula should be labeled with the child's name and should be
    used only for the intended child.

-   Breastmilk or formula should be warmed in a pan of hot, not boiling,
    water for 5 minutes. The bottle should then be shaken, and the milk
    temperature tested before feeding.

-   Microwaves should never be used to heat bottles of formula or
    breastmilk.

-   Any contents remaining in a bottle of formula or breastmilk after
    feeding should be discarded.

-   Prepared bottles of formula should be discarded after 24 hours if
    not used.

-   Once opened, containers of ready-to-feed or concentrated formula
    should be kept covered and refrigerated. They should be discarded
    after 48 hours if not used.

-   Unused, expressed breastmilk should be discarded after 48 hours if
    refrigerated, or after 2 weeks if frozen.

**Choking Prevention**

-   Precautions against choking should be taken when feeding infants and
    toddlers.

-   Caregivers should not offer to children under 4 years of age any
    foods that are implicated in choking incidents (including foods that
    are round, hard, small, thick and sticky, smooth, or slippery).
    Examples of these foods are hot dogs (whole or sliced into rounds),
    whole grapes, hard candy, nuts, seeds, raw peas, hard pretzels,
    chips, peanuts, popcorn, marshmallows, spoonfuls of peanut butter,
    carrot and celery sticks, and chunks of meat larger than can be
    swallowed whole.

**Feeding Schedules**

-   The caregiver should provide nutritious meals according to a written
    plan.

-   The caregiver should ensure that:

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-   Children in care for 8 and fewer hours are offered at least one
    nutritious meal and two nutritious snacks **or** two meals and one
    snack;

-   Children in care for more than 8 hours are offered at least two
    meals and two snacks **or** three meals and one snack;

-   A nutritious snack is offered to all children in midmorning and in
    midafternoon;

-   Children are offered food at intervals of not less than 2 hours
    apart and not more than 3 hours apart unless the child is asleep.

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-   Caregivers should feed infants on demand unless the parent provides
    written instructions otherwise.

-   Individuals responsible for food preparation or service should be
    free of contagious disease.

**CARE OF ILL CHILDREN**

**Principle**

*Reasonable exclusion criteria for ill children benefit all children in
the child care group, their caregivers, and their parents.*

**Why This Is Important**

-   • Many illnesses can be spread from person to person, particularly
    among young children in group care where diapers, drooling, and
    frequent hand to mouth behavior increase the likelihood of disease
    transmission.

-   • Children with more than mild infectious diseases can pose a safety
    hazard to other children by requiring a disproportionate amount of
    the caregiver's attention.

**Standards**

-   A written policy for determining inclusion, exclusion, and dismissal
    of ill children should be implemented.

-   A child should be excluded from the program if:

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-   The child does not feel well enough to participate comfortably in
    the usual activities of the program;

-   The caregivers cannot care for the sick child without interfering
    with the care of the other children; or

-   Keeping the child in care poses an increased risk to other children
    or adults in the child care facility, as determined by the caregiver
    or, if necessary, a local health official.

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-   A written plan should be in place for caring for an ill child.

-   A written plan should be in place addressing the administration of
    any medication (prescription or over-the-counter) to children in
    care.

**CAREGIVER HEALTH**

**Principle**

*Policies addressing caregiver health are important for ensuring a
healthy and safe child care environment.*

**Why This Is Important**

-   Caregivers can spread disease to children, and children can spread
    disease to caregivers.

-   Caregivers who are physically and emotionally healthy are likely to
    provide a higher quality of care to children than those who are ill.

-   Certain diseases that children may acquire and transmit to others,
    such as cytomegalovirus (CMV), rubella, and parvovirus, may pose
    additional risks for caregivers who are pregnant.

-   Other diseases such as toxoplasmosis and listeria that can be
    transmitted through contact with food, feces, and animals may also
    pose a risk to pregnant caregivers.

**Standards**

-   Policies should be developed for maintaining and addressing issues
    related to caregiver health. The policies should include:

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-   Guidelines for exclusion for illness and the subsequent return to
    work;

-   Information on the major occupational health hazards for caregivers;
    and

-   Stress management techniques.

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-   A policy should be in place to ensure that all caregivers are
    physically and emotionally able to care for children. The policy may
    include an option to request that a caregiver provide a statement of
    physical fitness to care for young children from his/her doctor or
    other primary health care professional.

**APPENDIX**

**STANDARD PRECAUTIONS**

From *Caring for Our Children: National Health and Safety Performance
Standards: Guidelines for Out-of-Home Child Care Programs, Second
Edition,* (2002), page 419:

**CLEANING UP BODY FLUIDS**

Treat urine, stool, vomitus, blood, and body fluids as potentially
infectious. Spills of body fluid should be cleaned up and surfaces
sanitized immediately.

-   For small amounts of urine and stool on smooth surfaces; Wipe off
    and clean away visible soil with a little detergent solution. Then
    rinse the surface with clean water.

-   Apply a sanitizer to the surface for the required contact time.

**For larger spills on floors, or any spills on rugs or carpets:**

-   Wear gloves while cleaning. While disposable gloves can be used,
    household rubber gloves are adequate for all spills except blood and
    bloody body fluids. Disposable gloves should be used when blood may
    be present in the spill.

-   Take care to avoid splashing any contaminated material onto the
    mucous membranes of your eyes, nose or mouth, or into any open sores
    you may have.

-   Wipe up as much of the visible material as possible with disposable
    paper towels and carefully place the soiled paper towels and other
    soiled disposable material in a leak-proof, plastic bag that has
    been securely tied or sealed. Use a wet/dry vacuum on carpets, if
    such equipment is available.

-   Immediately use a detergent, or a disinfectant-detergent to clean
    the spill area. Then rinse the area with clean water.

-   For blood and body fluid spills on carpeting, blot to remove body
    fluids from the fabric as quickly as possible. Then spot clean the
    area with a detergent-disinfectant rather than with a bleach
    solution. Additional cleaning by shampooing or steam cleaning the
    contaminated surface may be necessary.

-   Sanitize the cleaned and rinsed surface by wetting the entire
    surface with a sanitizing solution of bleach in water (1/4 cup of
    household bleach in 1 gallon of water) or an industrial sanitizer
    used according to the manufacturer\'s instructions. For carpets
    cleaned with a detergent-disinfectant, sanitizing is accomplished by
    continuing to apply and extract the solution until there is no
    visible soil. Then follow the manufacturer\'s instructions for the
    use of the sanitizer to be sure the carpet is sanitized by the
    treatment.

-   Dry the surface.

-   Clean and rinse reusable household rubber gloves, then treat them as
    a contaminated surface in applying the sanitizing solution to them.
    Remove, dry and store these gloves away from food or food surfaces.
    Discard disposable gloves.

-   Mops and other equipment used to clean up body fluids should be:

    1.  Cleaned with detergent and rinsed with water;

    2.  Rinsed with a fresh sanitizing solution;

    3.  Wrung as dry as possible;

    4.  Air-dried.

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-   Wash your hands afterward, even though you wore gloves.

-   Remove and bag clothing (yours and those worn by children) soiled by
    body fluids.

-   Put on fresh clothes after washing the soiled skin and hands of
    everyone involved.

***References:***

Canadian Paediatric Society. *Well Being: A Guide to Promote the
Physical Health, Safety and Emotional Well-Being of Children in Child
Care Centers and Family Day Care Homes,* 2nd ed. Toronto, ON; 1996.

Centers for Disease Control and Prevention. *The ABC\'s of Safe and
Healthy Child Care;* 1996.

Centers for Disease Control and Prevention. Guidelines for Prevention of
Transmission of Human Immunodeficiency Virus and Hepatitis B Virus to
Health-Care and Public Safety Workers. *MMWR.* 1989; 38(S-6): 1-36.

Centers for Disease Control and Prevention. Update: Universal
precautions for prevention of transmission of Human immunodeficiency
virus, hepatitis B Virus, and other bloodborne pathogens in healthcare
settings. *MMWR.* 1988; 37: 377-382, 387-388.

**RESOURCE LIST**

Numerous publications and organizations exist to provide information and
guidance on health and safety in child care programs. A sampling of key
resources is provided below.

**PUBLICATIONS AND ONLINE RESOURCES**

*Caring for Our Children: National Health and Safety Performance
Standards: Guidelines for Out-of-Home Child Care, Second Edition*
(2002). Published by the American Academy of Pediatrics, the American
Public Health Association, and the National Resource Center for Health
and Safety in Child Care. Available in fulltext online at
http://nrc.uchsc.edu/.

> *Caring for Our Children* is a comprehensive set of more than 600
> health and safety standards for child care programs serving children
> from birth to age 12. The standards in this Guide are designed to be
> consistent with those in *Caring for Our Children*.

*Stepping Stones to Using* Caring For Our Children*, 2nd Edition*
(2003). Published by the American Academy of Pediatrics, the American
Public Health Association, and the National Resource Center for Health
and Safety in Child Care. Available in full-text online at
http://nrc.uchsc.edu/.

> *Stepping Stones* contains a subset of the standards in *Caring for
> Our Children* that are believed to have the greatest impact on
> preventing disease, disability, and death in child care programs.
> *Stepping Stones* was designed to augment *Caring for Our Children,*
> providing policymakers and program managers with an abridged tool to
> assist with the development of effective child care policies and
> regulations.

Head Start National Training Guides. Published by the Head Start Bureau,
Administration for Children and Families, U.S. Department of Health and
Human Services. Available in full-text online from the Head Start
Information and Publication Center (HSIPC) at
http://www.headstartinfo.org/publications/trainingguides.cfm.

> Head Start's series of National Training Guides includes a number of
> publications on health and safety topics, including *Caring for
> Children with Chronic Conditions*, *Enhancing Health in the Head Start
> Workplace*, *Preventing and Managing Communicable Diseases*, and
> *Safety First: Preventing and Managing Childhood Injuries*. The HSIPC
> also provides access to other publications and links on health,
> safety, child development, and other related topics through their Web
> site, http://www.headstartinfo.org.

**ORGANIZATIONS**

**American Academy of Pediatrics (AAP)**

Department of Community Pediatrics

Early Education and Child Care Initiatives

141 Northwest Point Blvd

Elk Grove Village, IL 60007

Phone (toll-free): 1-888-227-5409

Fax: 847-228-6432

E-mail: childcare@aap.org

Web site: http://healthychildcare.org/

AAP offers resources and links on child care health topics. In addition
to providing free and low-cost materials for parents and providers, AAP
can also help connect programs to state and local resources and
contacts.

**National Association for Regulatory Administration (NARA)**

Eastern Office

910 Glen Falls Court

Newark, DE, 19711

Phone: 302-234-4152

Fax: 302-234-4153

E-mail: Paulinekoch@aol.com

Web site: http://www.nara-licensing.org/

NARA is a membership organization for professionals working in the field
of human service regulation, including child care licensing. They
provide technical assistance/consultation and training in all aspects of
regulation and monitoring.

**National Child Care Information Center (NCCIC)**

10530 Rosehaven St., Suite 400

Fairfax, VA 22030

Phone (toll-free): 1-800-616-2242

Fax (toll-free): 1-800-716-2242

TTY (toll-free): 1-800-516-2242

E-mail: info@nccic.org

Web site: http://nccic.org

NCCIC, a clearinghouse funded by the Child Care Bureau, responds to
requests for information from the general public on child care issues.
NCCIC's comprehensive Web site provides access to a vast array of links
and publications on early care and education topics, including health
and safety. NCCIC's online State Profiles provide state-specific
demographic, statistical, and licensing data, as well as contact
information for statewide resources such as child care resource and
referral (CCR&R) agencies.

**National Resource Center for Health and Safety in Child Care (NRC)**

UCHSC at Fitzsimons

Campus Mail Stop F541; PO Box 6508

Aurora, CO 80045-0508

Phone (toll-free): 1-800-598-KIDS (5437)

Fax: 303-724-0960

E-mail: natl.child.res.ctr@uchsc.edu

Web site: http://nrc.uchsc.edu/

The federally-funded NRC's mission is to promote health and safety in
out-ofhome child care settings. NRC provides question-and-answer
services, as well as full-text online access to a variety of health and
safety resources, such as *Caring for Our Children*, *Stepping Stones*,
and all State licensing regulations.

**Tribal Child Care Technical Assistance Center (TriTAC)**

6858 Old Dominion Drive, Suite 302

McLean, VA 22101

Phone (toll-free): 1-800-388-7670

Fax: 703-821-8626

E-mail: tritac2@aol.com

Web site: http://nccic.org/tribal/

TriTAC, funded by the Child Care Bureau, assists Indian Tribes and
tribal organizations in their efforts to enhance the quality,
affordability, and availability of child care. TriTAC responds to
requests for information about tribal child care and provides an
extensive Web site of links and publications on tribal early care and
education topics.

This Guide was developed by the Tribal Child Care Technical Assistance
Center under PSC Contract Number 233-03-0021, Task Order Number 2 for
the U.S. Department of Health & Human Services, Administration for
Children and Families, Child Care Bureau.

June 2005