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Babysitter’s Report Record

1. Household Rules and Discipline

    a. I noticed these good behaviors:

    ________________________________________________________________________________________

    b. I used the discipline technique you asked me to use when:

    ________________________________________________________________________________________

2. Safety

a. We received the following phone calls and visitors:

Date/time	Name	Reason for calling or visiting	Phone number to reach the caller or visitor

b. The following accidents and illnesses happened while you were gone:

Date/time	What happened	What I did	What the child did

3. Play

    a. We played with the following games and toys:

    ________________________________________________________________________________________

    b. I noticed these good behaviors while we were playing:

    ________________________________________________________________________________________

    ________________________________________________________________________________________

4.Basic Care

    a. We ate the following foods:

    ________________________________________________________________________________________

    b. _______________________________________ had naptime/went to bed at_____________.

    _______________________________________ had naptime/went to bed at_____________.

    c. For ____________________ I changed the diaper/helped with toileting _____ times

    and I noticed _____________________________________________________________________.

    d. For ____________________ I changed the diaper/helped with toileting _____ times

    and I noticed _____________________________________________________________________.

5.Other Comments

    ________________________________________________________________________________________

    ________________________________________________________________________________________

    ________________________________________________________________________________________

    ________________________________________________________________________________________

I gave _______________________________________ (child’s name) the following medications and amounts

exactly as instructed by _________________________________________ (parent or guardian):

Time: _______________Medicine: _______________________

Amount Given:_________________________

Any Reactions: _____________________________________________________________________________________

I provided the following first aid care for _________________________________________(child’s name).

What happened: _____________________________________________________________________________________

Where was the injury: ______________________________________________________________________________

When did it happen: ________________________________________________________________________________

What the child reported: ___________________________________________________________________________

What I did: ________________________________________________________________________________________