Washington County Forms

2. Washington County is required to solicit evaluations from parents before relicensing family child care providers. Information provided will be part of the agency's assessment and maintained in the provider's file. If you provide information that indicates possible licensing violations, we are required to conduct an investigation. We hope you will take the opportunity to complete this form which will provide us with input regarding your child(ren)'s child care provider and environment.

4. Provider's Name*
5. Licensor's Name
7. License Capacity
   • A:  10 total children of which 6 may be under school age; no more than 3 under age 2.
   • C1:  10 total children of which 8 may be under school age; no more than 3 under age 2.
   • C2: 12 total children of which 10 may be under school age; no more than 2 under age 2.
   • C3:  (2 adults needed) 14 total children of which 10 may be under school age; no more than 4 under age 2.
     • *OR must operate as a C1 or C2 if only 1 adult present
9. Do you currently have a child(ren) enrolled in this home?*

   1. Yes

   1. No
11. If no, what was the main reason you left?*
13. How long have you used this provider for care?*

15. Please rate the provider:

17. Provides an adequate supply of age-appropriate materials and activities.*

    1. Strongly Agree
    2. Agree

    1. Neutral
    2. Disagree

    1. Strongly Disagree
    2. NA (not applicable)
19. Provides nutritious meals and snacks.*

    1. Strongly Agree
    2. Agree

    1. Neutral
    2. Disagree

    1. Strongly Disagree
    2. NA (not applicable)
21. Provider changes diapers as frequently as needed.*

    1. Strongly Agree
    2. Agree

    1. Neutral
    2. Disagree

    1. Strongly Disagree
    2. NA (not applicable)
23. I am satisfied with communication with the provider.*

    1. Strongly Agree
    2. Agree

    1. Neutral
    2. Disagree

    1. Strongly Disagree
    2. NA (not applicable)
25. Provider is able to adequately care for the number and age distribution of children in his/her care.*

    1. Strongly Agree
    2. Agree

    1. Neutral
    2. Disagree

    1. Strongly Disagree
    2. NA (not applicable)
27. Provider guides behavior in a constructive, age-appropriate manner.*

    1. Strongly Agree
    2. Agree

    1. Neutral
    2. Disagree

    1. Strongly Disagree
    2. NA (not applicable)
29. Provider's home is clean and safe for children.*

    1. Strongly Agree
    2. Agree

    1. Neutral
    2. Disagree

    1. Strongly Disagree
    2. NA (not applicable)
31. The children are taken outdoors on a daily basis, weather premitting.*

    1. Strongly Agree
    2. Agree

    1. Neutral
    2. Disagree

    1. Strongly Disagree
    2. NA (not applicable)
33. I am satisfied with the condition of the toys and equipment used for the children.*

    1. Strongly Agree
    2. Agree

    1. Neutral
    2. Disagree

    1. Strongly Disagree
    2. NA (not applicable)
35. I am satisfied with the overall quality, consistency and stability of care provided.*

    1. Strongly Agree
    2. Agree

    1. Neutral
    2. Disagree

    1. Strongly Disagree
    2. NA (not applicable)
37. The outdoor play area is safe and free from hazards.*

    1. Strongly Agree
    2. Agree

    1. Neutral
    2. Disagree

    1. Strongly Disagree
    2. NA (not applicable)
39. Provider adequately supervises children inside and outside.*

    (Provider is within sight or hearing of infants, toddlers and preschoolers so the caregiver is capable of intervening. For school-age children, the caregiver is available for assistance so the child's health and safety are protected.)

    1. Strongly Agree
    2. Agree

    1. Neutral
    2. Disagree

    1. Strongly Disagree
    2. NA (not applicable)
41. Describe the provider's strong points or assets in the care they provide.
43. What types of learning activities are provided for your child?
45. Describe the sleep space provided for your child(ren).

    (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.)

47. 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?
49. Is there anything else you would like our agency to be aware of regarding this provider or home?
51. Have you been provided with a copy of your provider's policies including grievance and chemical use?*

    1. Yes

    1. No

    1. Not sure
53. Do you authorize the release of this information to the provider?*

    (The licensor may share the actual form with the provider.)

    1. Yes

    1. No
55. Parent's Name*
56. Parent's Phone #*
58. Date Submitted*
    Date Submitted

60. Do you have a fantastic child care provider?

    Want to nominate them for the Washington County Provider of the Year?

    If yes, see our online nomination form on the Child Care Licensing website.

Leave This Blank:


62. 1. Receive an email copy of this form.
63. Email address

    This field is not part of the form submission.

64. Submit Submit and Print

* indicates a required field