APPENDIX F: ENROLLMENT/ATTENDANCE/SYMPTOM RECORD

Classroom ______________

Month ______________ 20__

NAME		AGE IN MONTHS	DAILY HOURS IN CARE	FOR EACH CHILD, EACH DAY CODE TOP BOX "+" = PRESENT or "O" = ABSENT, N = NOT SCHEDULED CODE BOTTOM BOX "O" = WELL or " " SYMPTOM CODE FROM BOTTOM OF PAGE.
				1	2	3	4	5	6	7	8	9	10	11	12	13	14	15	16	17	18	19	20	21	22	23	24	25	26	27	28	29	30	31
TOTAL PLACED ON REGISTER			NUMBER OF DAYS FACILITY WAS OPEN

Symptom Codes: 1 = ASTHMA, WHEEZING, 2 = BEHAVIOR CHANGE WITH NO OTHER SYMPTOM, 3 = DIARRHEA, 4 = FEVER, 5 = HEADACHE, 6 = RASH, 7 = RESPIRATORY (COLD, COUGH, RUNNY NOSE, EARACHE, SORE THROAT, PINK EYE), 8 = STOMACHACHE, 9 = URINE PROBLEM, 10 = VOMITING, 11 = OTHER (SPECIFY ON BACK OF FORM)

Reference: Pennsylvania Chapter, American Academy of Pediatrics. Model Child Care Health Policies. 3rd ed. Washington D.C: National Association for the Education of Young Children, 1997.

This form was adapted and updated from Model Child Care Health Policies, June 1997, by the Early Childhood Education Linkage System (ECELS), a program funded by the Pennsylvania Depts. of Health & Public Welfare and contractually administered by the PA Chapter, American Academy of Pediatrics.