Beverly Hills Resources Corporation Infant Care Center
6556 Fountain Avenue, Los Angeles, CA 90028
Date:______
Needsand Service Plan (For Infants and Children with Special Needs) (CCR Title 22, Section 101419.2). The objective of this plan is to extract all possible information from the parents of infants on how best the center can take good care of all infants in its facility. This is accomplished through series of questionnaires for the parents to answer on (A) Feeding, (B) Toileting, C) Napping and (D) Special Needs Plan which are given to them as soon as they enroll their children. Shown below is the format of the Needs and Service Plan.
Infant’s Needs and Service Plan
Infant’s Name:______Age: ______
Parent’s Name:______Tel. No: ______
Parent’s Address:______
Parents, please answer the following:
A. Feeding Care Plan:(What, how, when and how often)
1. What are the infant’s food allergies? Please list all food allergies
2. What kind of food do you usually feed your child’s present age? ______
3. What do you do to the child after feeding? Burp the infant? ( ) Yes ( ) No. Let the infant sit? ( ) Yes ( ) No. Put inside the crib ( ) Yes ( ) No. Others? Please explain ______
4. What feeding tube do you use? Disposable sanitary plastic tubes? ( ) Yes ( ) No. Regular plastic bottles ? ( ) Yes ( ) No. Regular glass bottles? ( ) Yes ( ) No Others? Please explain ______
5. What kind of milk formula do you give to your child? High iron fortified infant formula? ( ) Yes ( ) No. Low iron fortified infant formula? ( ) Yes ( ) No. Regular Milk( ) Yes ( ) No. Soy milk low iron fortified infant formula?( ) yes ( ) No.
6. What kind of solid food do you give to your child? ______
7. How do you usually feed your child? Sitting on Feeding table? ( ) Yes ( ) No
In a reclining position? ( ) Yes ( ) No. Baby’s head elevated? ( ) Yes ( ) No. Carrying or holding the baby? ( ) Yes ( ) No. Others? Please explain ______
8. When do you usually feed your baby?______
9. When would you like us to give solid food to your child? ______
10. How often do you want us to feed your child?______
B.Toileting and Potty Training Plan: (What, how, when, how often)
I. What other substances your child is allergic of? Latex gloves? ( ) Yes ( ) No Powder?
( ) Yes ( ) No. Rash Ointment? ( ) Yes ( ) No. Please specify them______
2. What do you usually use for potty training? Regular toilet bowl with adapter?
( ) Yes ( ) No. Portable plastic toilet bowl? ( ) Yes ( ) No. Others?______
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3. What kind of diapers does your child use?______Pull up? ( ) Yes ( ) No. Instant grip? ( ) Yes ( ) No. Instant stick? ( ) Yes ( ) No. Others? Please enumerate ______
4. What do you usually give to your child when he/she has diarrhea? ( ) Yes ( ) No
5. Do you want us to put powder to your child every diaper change? ( )Yes ( ) No.
6. How do you know from a distance if your child needs a diaper change? ______
7. How do you know if your child wants to go the toilet?______
8. When do you want us to start potty training of your child? ______
9. Do you have additional instructions for us to do on the toileting or potty training of your child? ______
10. How often do you want us to change the diaper of your child? ______
C. Napping Plan:(What, how, when, how often)
1. What does your child need for napping? ______
2. What do you usually give to your child during naptime?______
3. What does your child like during nap time? ( ) Any particular toy:______
A special blanket? ( ) Yes ( ) No. Pacifier? ( ) Yes ( ) No. Bottle of milk? ( ) Yes ( ) No Bottle of pure fruit juice? ( ) Yes ( ) No. Others ? Please specify ______
4. What position does your child sleep? On his/her side’? ( ) Yes ( ) No. On his/her back’? ( ) Yes ( ) No. On his/her stomach? ( ) Yes ( ) No.
5. How do you put your child to sleep? ______
6. How long does your child take a nap? ______
7. Is there any particular music your child loves to hear at nap time’? _____ Please explain ______
8. Is your child sensitive to light? ( ) Yes ( ) No. To noise? ( ) Yes ( ) No.
9. When do you usually put your child to sleep? ______
10. How often do you want us to let your child sleep during the day? ______
11. Do you have any other recommendation on the napping of your child? ______
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D. Special Needs Plan:(What, how, when, how often)
1. What are the special needs of your child? Please explain fully. ______
2. What are the special health concerns you have for your child? ______
3. How can we better serve these needs to your child?______
4. Does your child need special chair, special feeding chair, special feeding equipment. special walker for motor coordination? Please specify ______
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5. Do you use any special breathing equipment for your child in case of attack?______
6. Please describe any difficulties you noticed which are associated with each condition of breathing attack? ______
7. Does your child have prolonged seizure, epilepsy attack or blood sugar drop? Please specify: ______
8. When does your child need an inhaler or an insulin shot? Please specify ______
9. How often shall we administer medication or using adaptive equipment such as a
special type of walker or inhaler?______
10. How often and how what solid food do you want your child to be fed? ______
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E. Special Instructions:______
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(Parent’s Signature)