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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) 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. 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
11. First and Last Name*
12. Date*
    Date
14. Your Address*
15. Phone Number*
19. Do you currently have a child(ren) enrolled in this home?

    1. Yes

    1. No
20. Ages of child(ren)
22. How long have you used/or did you use this home?
24. 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
26. 1. This provider welcomes children and parents when they arrive, helping children to feel comfortable and safe as parents leave.

    1. 5
    2. 4
    3. 3
    4. 2
    5. 1
    6. N/A
28. 2. This provider's home is clean and safe for children.

    1. 5
    2. 4
    3. 3
    4. 2
    5. 1
    6. N/A
30. 3. This provider offers healthy meals and snacks.

    1. 5
    2. 4
    3. 3
    4. 2
    5. 1
    6. N/A
32. 4. This provider plans activities for each day that include active play, quiet time, and outside play in most weather.

    1. 5
    2. 4
    3. 3
    4. 2
    5. 1
    6. N/A
34. 5. The outdoor play area is safe and free from hazards.

    1. 5
    2. 4
    3. 3
    4. 2
    5. 1
    6. N/A
36. 6. 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
38. 7. This provider listens to children instead of just giving them directions or correcting.

    1. 5
    2. 4
    3. 3
    4. 2
    5. 1
    6. N/A
40. 8. This provider sets behavior limits for children that make sense.

    1. 5
    2. 4
    3. 3
    4. 2
    5. 1
    6. N/A
42. 9. This provider handles discipline without hitting (or other physical punishment) or shaming children.

    1. 5
    2. 4
    3. 3
    4. 2
    5. 1
    6. N/A
44. 10. This provider can handle children's behavior positively by showing them something else to do.

    1. 5
    2. 4
    3. 3
    4. 2
    5. 1
    6. N/A
46. 11. This provider can care for the number of children they have in their care.

    1. 5
    2. 4
    3. 3
    4. 2
    5. 1
    6. N/A
48. 12. Provider changes diapers as frequently as needed.

    1. 5
    2. 4
    3. 3
    4. 2
    5. 1
    6. N/A
50. 13. This provider is always supervising children both indoor and outside.

    1. 5
    2. 4
    3. 3
    4. 2
    5. 1
    6. N/A
52. 14. Describe the sleep space provided for your child(ren).
54. 15. 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?
56. 16. Is there anything else you would like our agency to be aware of regarding this provider or home?
58. Additional comments (is there anything else you would like our agency to be aware of regarding this provider or the home?)
60. 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.

    Family Childcare Licensing
    Anoka County Government Center
    2100 3rd Avenue, Suite 500
    Anoka, MN 55303-5049

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64. 1. Receive an email copy of this form.
65. Email address

    This field is not part of the form submission.

66. Submit

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