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CARING FOR OUR CHILDREN

CARING FOR
OUR CHILDREN

National Health and Safety Performance Standards:

Guidelines for Out-of-Home Child Care
Second Edition

A Joint Collaborative Project of

American Academy of Pediatrics
141 Northwest Point Blvd.
Elk Grove Village, IL 60007-1098
American Public Health Association
8001 I Street, N.W.
Washington, DC 20001-3710
National Resource Center for Health and Safety in Child Care
University of Colorado Health Sciences Center at Fitzsimons
Campus Mail Stop F541, PO Box 6508
Aurora, CO 80045-0508

Support for this project was provided by the

Maternal and Child Health Bureau,
Health Resources and Services Administration,
Department of Health and Human Services
(Cooperative Agreement # U93 MC 00098)
 VERSO

Copyright 2002 by
American Academy of Pediatrics
American Public Health Association
National Resource Center for Health and Safety in Child Care

All rights reserved. This book is protected by copyright. No part of this book
may be reproduced in any form or by any means, including photocopying, or
utilized by any information storage and retrieval system without the prior
written permission of the publisher.

For reprint requests, please contact the Permissions Editor at the American
Academy of Pediatrics by fax 847-434-8780 or mail American Academy of
Pediatrics, PO Box 927, Elk Grove Village, IL 60006-0927

The National Standards are for reference purposes only and shall not be used
as a substitute for medical consultation, nor be used to authorize actions
beyond a person’s licensing, training, or ability.

ISBN 1-58110-079-5 (American Academy of Pediatrics)

0-9715682-0-0 (National Resource Center for Health and Safety
in Child Care)

Printed and bound in the United States of America

Design: Jeff Calderone, Kathy Duran, David Merten
Typesetting: Jeff Calderone, David Merten
 TABLE OF
Caring for Our Children: Table of Contents
National Health and Safety Performance Standards
TABLE OF CONTENTS
Acknowledgments ...................................................................................................................................vii
Introduction .............................................................................................................................................. xiii
Advice to Users...................................................................................................................................... xvii

Chapter 1 – Staffing ................................................................................................................................. 1

1.1 Child:Staff Ratio and Group Size ............................................................................................... 3
1.2 Licensure/Certification of Qualified Individuals ..................................................................... 6
1.3 Preservice Qualifications and Special Training........................................................................ 7
1.4 Training .......................................................................................................................................... 17
1.5 Substitutes .................................................................................................................................... 30
1.6 Health Consultants ..................................................................................................................... 32
1.7 Staff Health ................................................................................................................................... 36
1.8 Staff Benefits ................................................................................................................................. 40
1.9 Performance Evaluation ............................................................................................................. 41

Chapter 2 - Program: Activities for Healthy Development ............................................... 45

2.1 Program of Developmental Activities..................................................................................... 47
2.2 Supervision ................................................................................................................................... 58
2.3 Transportation ............................................................................................................................. 60
2.4 Discipline....................................................................................................................................... 64
2.5 Parent Relationships ................................................................................................................... 66
2.6 Health Education ......................................................................................................................... 74

Chapter 3 – Health Promotion and Protection in Child Care .......................................... 83

3.1 Health Promotion in Child Care ............................................................................................. 85
3.2 Hygiene.......................................................................................................................................... 91
3.3 Sanitation, Disinfection, and Maintenance........................................................................... 104
3.4 Health Protection in Child Care............................................................................................ 111
3.5 Special Medical Conditions in Young Children................................................................... 118
3.6 Management of Illness .............................................................................................................. 123

Chapter 4 – Nutrition and Food Service ................................................................................... 147

4.1 Introduction................................................................................................................................149
4.2 General Requirements.............................................................................................................149
4.3 Requirements for Special Groups or Ages Of Children ..................................................155
4.4 Staffing..........................................................................................................................................163
4.5 Meal Service, Seating, and Supervision.................................................................................165
4.6 Food Brought From Home .....................................................................................................169
4.7 Kitchen and Equipment............................................................................................................170
4.8 Food Safety .................................................................................................................................173
4.9 Maintenance ...............................................................................................................................178
4.10 Meals From Outside Vendors or Central Kitchens ........................................................181
4.11 Nutrition Learning Experiences and Education ...............................................................182

Chapter 5 – Facilities, Supplies, Equipment, and Transportation .................................187

5.1 Overall Space and Equipment Requirements......................................................................189
5.2 Space and Equipment in Designated Areas .........................................................................235
5.3 Active Play Indoor and Outdoor Areas ..............................................................................253
5.4 Swimming, Wading, and Water..............................................................................................264
5.5 Interior and Exterior Walkways, Steps, and Stairs............................................................271
5.6 Maintenance for Safety.............................................................................................................272
5.7 Transportation ...........................................................................................................................274

iii Table of Contents

Table of Contents Caring for Our Children:
National Health and Safety Performance Standards

Chapter 6 – Infectious Diseases .....................................................................................................283

6.1 Respiratory Tract Infections ...................................................................................................285
6.2 Herpes Viruses ..........................................................................................................................293
6.3 Enteric (Diarrheal) and Hepatitis A Virus (HAV) Infections ...........................................296
6.4 Bloodborne Infections..............................................................................................................300
6.5 Skin Infections ............................................................................................................................305

Chapter 7 – Children Who are Eligible for Services Under IDEA................................313

7.1 Guiding Principles for this Chapter and Introduction ......................................................315
7.2 Inclusion of Children With Special Needs in the Child Care Setting ...........................317
7.3 Process Prior to Enrolling at a Facility .................................................................................318
7.4 Developing a Service Plan for a Child With Special Needs ............................................319
7.5 Coordination and Documentation........................................................................................323
7.6 Periodic Reevaluation...............................................................................................................324
7.7 Assessment of Facilities for Children With Special Needs .............................................325

Chapter 8 – Administration .............................................................................................................331

8.1 Identifiable Governing Body/Accountable Individual.........................................................333
8.2 Management and Health Policies and Statement of Services..........................................334
8.3 Program of Activities................................................................................................................355
8.4 Personnel Policies .....................................................................................................................357
8.5 Written Statement of Services ..............................................................................................358
8.6 Special Needs Plan ....................................................................................................................359
8.7 Records .......................................................................................................................................359
8.8 Posting Documents...................................................................................................................376
8.9 Contracts ....................................................................................................................................378
8.10 Drop-in Care ...........................................................................................................................378

Chapter 9 – Licensing and Community Action ......................................................................381

9.1 The Regulatory Agency ...........................................................................................................383
9.2 Health Department Responsibility........................................................................................392
9.3 Training ........................................................................................................................................400
9.4 Program Development.............................................................................................................401
9.5 Regulatory Coordination ........................................................................................................402
9.6 Public Policy Issues and Resource Development...............................................................403

Appendices ...............................................................................................................................................407
A – Guiding Principles for the Standards.................................................................................409
B – Major Occupational Health Hazards.................................................................................410
C – Nutrition Specialist and Child Care Food Service Staff Qualifications .....................411
D – Gloving .....................................................................................................................................412
E – Child Care Staff Health Assessment .................................................................................413
F – Enrollment/Attendance/Symptom Record.......................................................................414
G – Recommended Childhood Immunization Schedule.......................................................415
H – Recommendations for Preventive Pediatric Health Care ............................................416
I – Selecting an Appropriate Sanitizer.....................................................................................417
J – Cleaning Up Body Fluids ......................................................................................................419
K – Clues to Child Abuse and Neglect....................................................................................420
L – Risk Factors for Abuse and/or Neglect............................................................................421
M – Special Care Plan for a Child With Asthma ....................................................................422
N – Situations that Require Medical Attention Right Away ................................................424
O – Food Guide Pyramid .............................................................................................................425

Table of Contents iv
Caring for Our Children: Table of Contents
National Health and Safety Performance Standards

P – Child Care Infant Meal Pattern ..........................................................................................426

Q – Meal Pattern Requirements for Children Ages 1 through 12 Years ..........................427
R – Food Storage Chart ..............................................................................................................428
S – Sample Food Service Cleaning Schedule..........................................................................430
T – Adaptive Equipment for Children With Special Needs ................................................431
U – Poisonous Plants and Safe Plants........................................................................................434
V – Depth Required for Tested Shock-absorbing Surfacing Materials for Use Under
Play Equipment....................................................................................................................435
W – Permission for Medical Condition Treatment.................................................................436
X – Emergency Information Form for Children With Special Needs...............................437
Y – Incident Report Form...........................................................................................................439
Z – Child Health Assessment.....................................................................................................440
AA – Licensing and Public Regulation of Early Childhood Programs - NAEYC
Position .................................................................................................................................441
BB – Contact Information .............................................................................................................449
CC– Conversion Table – Standard Numbers From 1st Edition to 2nd Edition ...............459
DD– Conversion Table – Standard Numbers From 2nd Edition to 1st Edition ...............468

Glossary .....................................................................................................................................................479
Index............................................................................................................................................................495

v Table of Contents
Caring for Our Children: ACKNOWLEDG- Acknowledgments
National Health and Safety Performance Standards

ACKNOWLEDGMENTS Technical Panel

Chairs and Members
The National Resource Center for Health
and Safety in Child Care would like to acknowl- Children With Special Needs
edge the outstanding contributions of all persons Herbert J. Cohen, MD, FAAP, Chair,
and organizations involved in the revision of Caring Bronx, NY
for Our Children: National Health and Safety Perfor- Rebecca Fewell, PhD, Miami, FL
mance Standards: Guidelines for Out-of-Home Child Ruth Kaminer, MD, FAAP, Bronx, NY
Care Programs. Second Edition. The collaboration of Lillian Kornhaber, RPT, Bronx, NY
the American Academy of Pediatrics, the Ameri- Peggy Pizzo, MEd, Boston, MA
can Public Health Association, and the Maternal Anne Riley, RN, Iowa City, IA
and Child Health Bureau provided a wide scope of Sarah Schoen, MA, OT, Bronx, NY
technical expertise from their constituents in the Nancy Tarshis, MA, CCC/SP, Bronx, NY
creation of this project. The subject-specific Tech-
nical Panels as listed provided the majority of the Environmental Quality
content and resources. Over 100 organizations Steven B. Eng, MPH, RPHI, Chair,
were asked to review and validate the accuracy of BC, Canada
the content and contribute additional expertise Robert E. Brewster, RS, MPA, Wheaton, IL
where applicable. The individuals representing Lowest Jefferson, Olympia, WA
these organizations are listed in “Additional Con- Shannan Lile, RS, Arlington, TX
tributors”. This broad collaboration and review Lori Saltzman, Bethesda, MD
from the best minds in the field has led to a more Richard K. Snaman, REHS/RS, Arlington, VA
comprehensive and useful tool. Elizabeth Zanowiak, Washington, DC
In a project of such scope, many individu-
als provide valuable input to the end product. We General Health
would like to acknowledge those individuals Selma Deitch, MD, MPH, FAAP, Chair,
whose names may have been omitted. Manchester, NH
Joan H. Ascheim, MSN, Concord, NH
Steering Committee Karen Donoghue, RN, Manchester, NH
Steven Grandgeorge, MD, FAAP, Bedford, NH
Susan S. Aronson, MD, FAAP Richard Nordgren, MD, Lebanon, NH
Co-Chair, American Academy of Pediatrics, PA Carole Treen, Manchester, NH
Mary Jane Wallner, Concord, NH
Albert Chang, MD, MPH, FAAP Health and Safety Organization and
Co-Chair, American Public Health Association, CA Administration
Patricia Schloesser, MD, Chair, Topeka, KS
Phyllis E. Stubbs-Wynn, MD, MPH Chris Ross-Baze, MSW, Topeka, KS
Department of Health and Human Services, Ed Ehlinger, MD, Minneapolis, MN
Health Resources and Services Administration, Karen E. Kroh, BA, Harrisburg, PA
Maternal and Child Health Bureau, DC Shirley Norris, MA, Topeka, KS
Peggy Scally, RN, Lawrence, KS
Marilyn J. Krajicek, EdD, RN, FAAN Maureen Whitman, MN, Portland, OR
Director, National Resource Center for Health
and Safety in Child Care, CO

Barbara U. Hamilton, MA
Assistant Director, National Resource Center for
Health and Safety in Child Care, CO

vii Acknowledgments
Acknowledgments Caring for Our Children:
National Health and Safety Performance Standards

Health Concerns Related to Social Prevention and Management of Child

Environment and Child Development Abuse
Albert J. Solnit, MD, FAAP, Chair, David Chadwick, MD, FAAP, Co-Chair,
New Haven, CT San Diego, CA,
Jean Adnopoz, MPH, New Haven, CT Carole Jenny, MD, FAAP, Co-Chair,
Angela Crowley, PhD, APRN, CS, PNP Providence, RI
New Haven, CT Deborah E. Lowen, MD, FAAP, Stratford, NJ
Cynthia Farrar, New Haven, CT Patti K. Rosquist, MD, FAAP, Denver, CO
Lola Nash, MA, New Haven, CT Charles J. Schubert, MD, FAAP, Cincinnati, OH
June Sale, Los Angeles, CA Sara E. Schuh, MD, FAAP, Charleston, SC
Kathryn Young, PhD, Riverside, CT John R. Stirling, Jr., MD, FAAP, Vancouver, WA
Susan Reichert, MD, FAAP, Bend, OR
Infectious Diseases
Larry Pickering, MD, FAAP, Chair, Staff Health
Atlanta, GA Iris Graville, RN, MN, Chair, Lopez Island, WA
Ralph L. Cordell, PhD, Atlanta, GA Judy Calder, RN, BSN, Berkley, CA
Leigh G. Donowitz, MD, FAAP, Charlottesville, VA Julianne Crevatin, MPH, Seattle, WA
Fred Henderson, MD, Chapel Hill, NC Susan Eckelt, CDA, Tulsa, OK
Pauline D. Koch, MS, Wilmington, DE Rene Gratz, PhD, Milwaukee, WA
Dennis L. Murray, MD, FAAP, Augusta, GA Jan Gross, RN, BSN, Greenbank, WA
Robert F. Pass, MD, FAAP, Birmingham, AL Karen Liberanti, RN, BSN, Tempe, AZ
James M. Poole, MD, FAAP, Raleigh, NC Lynn Manfredi/Petitt, BS, Atlanta, GA
Daria Miller, Sunnyside, WA
Injury Prevention Lynn White, BA, Conyers, GA
Albert Chang, MD, MPH, FAAP, Chair,
San Diego, CA
Abbey Alkon, RN, MPH, PhD, Berkeley, CA
Letty Lie, RN, MPH, Minneapolis, MN
Cheryl Neverman, MS, Washington, DC Lead Organizations Review
Joyce Rezin, RN, MS, PNP, San Diego, CA Groups
Ellen R. Schmidt, MS, OTR, Washington, DC

Nutrition American Academy of Pediatrics

Catherine Cowell, PhD, Chair, New York, NY Laura Aird, MS, Elk Grove Village, IL
Maryrose J. Baiano, MS, DD, Dobbs Ferry, NY Scott Allen, Chicago, IL
Donna Blum, MS, RD, Alexandria, VA Sophie J. Balk, MD, FAAP, Bronx, NY
Robin Brocato, MHS, Washington, DC Dana M. Brazdziunas, MD, FAAP, Maywood, IL
Annie Carr, MS, RD, Atlanta, GA Eileen Casey, MS, Elk Grove Village, IL
Ofelia Dirige, PhD, RD, San Diego, CA Peter A. Gorski, MD, MPA, FAAP, Boston, MA
Darby Eliades Graves, MPH, RD, Albany, OR Lawrence M. Gartner, MD, FAAP,
Janet Guidry, MPH, RD, New Orleans, LA Valley Center, CA
Brenda Lisa, MS, RD, Alexandria, VA Peter Michael Miller, MD, MPH, FAAP,
Mildred Monroe, MS, RD, LD, Atlanta, GA San Anselmo, CA
Suzanne Rigby, MS, RD, Alexandria, VA Jody R. Murph, MD, MS, FAAP, Iowa City, IA
Susan Schlosser, MS, RD, Chappaqua, NY Sheryl Nelson, MS, Elk Grove Village, IL
Ruth Shrock, MS, RD, Columbus, OH S. Donald Palmer, MD, FAAP, Sylacauga, AL
Denise Sofka, MPH, RD, Rockville, MD James M. Poole, MD, FAAP, Raleigh, NC
Frances Vines, MS, RD, Dallas, TX Judy Romano, MD, FAAP, Wheeling, WV
Jay Selcow, MD, FAAP, West Hartford, CT
Alicia Siston, MS, MPH, Elk Grove Village, IL
Howard R. Spivak, MD, FAAP, Boston, MA
Burton Willis, MD, FAAP, Fountain Valley, CA

Acknowledgments viii
Caring for Our Children: Acknowledgments
National Health and Safety Performance Standards

American Public Health Additional Contributors

Association
Duane Alexander, MD, FAAP
Jonathan B. Kotch, MD, MPH, FAAP, National Institute of Child Health and Human
Chapel Hill, NC Development, MD
Ellen T. Meyer, Washington, DC
Larry R. Olsen, DrPH, MPH, SHES, Towson, MD Sandra Anseth, RN
Mary B. Tierney, MD, Washington, DC North Dakota State Department of Health, ND
Billie Weiss, MPH, Los Angeles, CA
Sheri Azer, MA
Wheelock College Institute for Leadership and
U.S. Department of Health and Career Initiative, MA
Human Services Stan Bienick, BSW
Child Care Bureau Cherokee Center for Family Services, NC
Moniquin Huggins, Washington, DC
Heidi Bishop, BS
Maternal and Child Health Bureau United States Department of Agriculture, VA
Phyllis Stubbs-Wynn, MD, MPH, Rockville, MD
Yolanda Baker, Rockville, MD Donna Blum-Kemelor, MS, RD, LD
Stephanie Bryn, MPH, Rockville, MD United States Department of Agriculture, VA
David E. Heppel, MD, FAAP, Rockville, MD
Merle G. McPherson, MD, MPH, Rockville, MD Jo Ann Bolick, MA, CPNP, APN
Kerry Nesseler, RN, MS, Rockville, MD Arkansas Department of Health, AR
Mary Overpeck, DrPH, Rockville, MD
John Rossetti, DDS, MPH, Rockville, MD John A. Bogert, DDS
American Academy of Pediatric Dentistry, IL

J. Patrick Byrne
National Association for Regulatory
National Resource Center for Administration, NJ
Health and Safety in Child Care* Elaine Carr
Project Team Community & Family Health Services, AZ
Marilyn Krajicek, EdD, RN, FAAN - Director Gloria V. Chen, RN, MBA
Jennifer Beezley, RN, BA - Co-editor, Georgia Division of Public Health, Office of Infant
Former Research Assistant and Child Health, GA
Jeff Calderone, MBA - Former Research Assistant
Shannon Collins, RN, BSN, MSCIS - Health Consultant
Susan Epstein, - Editor Judy Collins, MS
Jeryl Feeley, ND, RN - Former Research Assistant National Association for Regulatory
William Freud, MBA - Assistant Vice Chancellor - Administration, OK
Information Systems, University of Colorado Health
Sciences Center Susan M. Conrath, PhD, MPH
Barbara Hamilton, MA - Assistant Director Environmental Protection Agency, DC
Rachel Haynes, ND, CPNP, MSN - Research Assistant
David Merten, BS - Research Assistant Ralph Cordell, PhD
Ruth Neil, PhD, RN - Former Project Coordinator Centers For Disease Control and Prevention, GA
Patricia Petch, BSc - Former Research Assistant
Elisabeth Rosenberg, BS - Program Assistant
Virginia Torrey, BA - Program Specialist Ron Coté, PE
Joy Wu, PhD - Fellow National Fire Protection Association, MA

* Based at the University of Colorado Health Sciences Jane Cotler, RN, MS, CSN
Center School of Nursing. Colorado Department of Public Health and
Environment, CO

ix Acknowledgments
Acknowledgments Caring for Our Children:
National Health and Safety Performance Standards

Jane Coury, MSN, RN Phil Koshkin

Formerly with Maternal and Child Health Bureau, Office of Licensing Child Care Administration, MD
PHS/Health Resources and Services
Administration, MD Jonathan B. Kotch, MD, MPH, FAAP
National Training Institute for Child Care Health
Angela Crowley, PhD, APRN, CS, PNP Consultants, NC
National Association of Pediatric Nurse
Practitioners, CT Karen E. Kroh, BA
National Association for Regulatory Administra-
Steve Davis, MD tion, PA
Kentucky Department of Public Health, KY
Christopher A. Kus, MD, MPH, FAAP
Butch DeFillippo, MA Rec Admin, CPSI, CPRP New York State Department of Health, NY
PlaySafe, LLC Recreational Consulting &
Services, NM Marlene Lee, BSN, RN
Maternal and Child Health Branch, Hawaii
Katherine Duchen-Smith, RN, MS, CPNP Department of Health, HI
National Association of Pediatric Nurse
Practitioners, CO Linda Likins
National Association Child Care Resource and
Susan Eckelt, CDA Referral Agencies, Inc, PA
National Association for Family Child Care, OK
Marjorie J. Long, Esq., CO
Lynn T. Elliott, RN, MS
Florida Department of Health, FL Doris Luckenbill, RN, CSN
National Association of School Nurses, Inc, ME
Maria Gil De Lamadrid, JD
Child Care Law Center, CA Deborah Markenson, MS, RD
Missouri Department of Health, Nutrition & Child
Melinda Green Care Programs, MO
National Black Child Development Institute, DC
Paul F. Marmen, MEd, EMT
Scott Groginsky Oklahoma Emergency Medical Services for
National Conference of State Legislatures, CO Children, OK

Peggy Haack Virginia Marx, AS

Center for the Child Care Workforce, DC National Association of Pediatric Nurse
Practitioners, NJ
Bruce Hershfield
Child Welfare League of America, DC Tameron Mitchell, RD, MPH
California Department of Health Services, Primary
Dawn Higley, RN, MS, CPNP Care and Family Health Division, CA
Formerly with Utah Department of Health, UT
Gwen Morgan, MS
Kay Hollestelle Wheelock College Institute for Leadership and
The Children’s Foundation, DC Career Initiative, MA

Gail Johnson, RN, MS Jim O’Brien, PhD

Formerly with National Association for Sick Child Head Start Bureau, DC
Day Care, VA
Kathleen Eaton Paterson, RN, MPH
Pauline D. Koch, MS Formerly with Vermont Department of Health, VT
National Association for Regulatory
Administration, DE Susan Ponemon
United States Department of Agriculture, VA

Acknowledgments x
Caring for Our Children: Acknowledgments
National Health and Safety Performance Standards

Paul S. Rusinko Lynn White, BA

Maternal and Child Health Bureau, MD National Child Care Association, GA

William A. Rutala, PhD Karen Williams, PhD

University of North Carolina, NC University of Wyoming, WY

Mary Schucker, CPNP, MSN, RN, CRNP Judith Wright

National Association of Pediatric Nurse Nevada State Health Division, NV
Practitioners, PA
Susan Zamecnik, MEd
Phyllis Sherard, MPA National Association for Regulatory
Wyoming Department of Health, WY Administration, VT

Wendelin Slusser, MD, FAAP, CA Robin Zelno

Formerly with American Society for Testing and
Linda Smith Materials, PA
Formerly with United States Department of
Defense, VA

Karen Sokal-Gutierrez, MD, MPH, FAAP, CA

This edition of Caring for Our Children: National Health
and Safety Performance Standards: Guidelines for Out-of
Patricia M. Spahr, MA Home Child Care Programs was based on the first edition.
National Association for the Education of Young For this reason the contributors of the second edition
Children, DC would like to acknowledge those involved in the cre-
ation of the first edition and their location at the time
Steven B. Steinhoff of publishing. They are: Olivia Alegre-Ipanag, MD, MPH;
Association of Food and Drug Officials, PA Madeline Appell, MA, New York, NY; Arthur L. Banks,
RS, Washington, DC; Glenda Bean, AR; David Beard,
Linda Stern MSW, Austin, TX; G. Scott Biebink, MD, Minneapolis,
Child Care Division, Oregon Department of MN; Judy Blanding, MSN, San Jose, CA; Helen Blank, BS,
Employment, OR Washington, DC; Janice Boase, RN, Seattle, WA; Joyce
Borgmeyer, IA; Elizabeth Brannon, MS, RD, Rockville,
MD; Janet Braunstein, RN, MPH, Halifax, NS; Seido
Carolynne Stevens, MA Baba Brodbeck, MPH; Albert H. Brunswasser, MPH,
National Association for Regulatory MBA, Pittsburgh, PA; Mojdeh Bruss, MPH, RD, Albu-
Administration, VA querque, NM; Susan Campbell, MPH; Bria Chakofsky,
RN, Seattle, WA; Barbara Chernofsky, La Mesa, CA;
Sandy Sullivan Norris Class, MS, Topeka, KS; Brenda Coakley, MA,
Formerly with The Clorox Company, DC Washington, DC; Steven Cochi, MD, Atlanta, GA; Judy
Coughlan, RN, Auburn, NY; Martha Daley, Denver, CO;
Jeanette S. Tanos, RN, MHR Dee Cuney, MEd, Napa, CA; Sheila Dobbin, MSW, Bos-
Guam Department of Public Health and Social ton, MA; Barry Fidel, MSW, Olympia, WA; David Finkel-
hor, PhD, Durham, NH; Leslie Fisher, MPH, Albany, NY;
Services, Guam Patricia Fosarelli, MD, Baltimore, MD; Judith Garrard,
PhD, Minneapolis, MN; Emily H. Gates, MD, Jackson-
Barbara Thompson, MS ville, FL; Helene Gayle, MD, MPH, Atlanta, GA; Andrea
United States Department of Defense, VA Gielen, MPH, Baltimore, MD; Benjamin Gitterman, MD,
CO; David Goff, PE, MS, Hamden, CT; Stacey Graville,
Donna Thompson, PhD RN, MN, Bellingham, WA; Elmer Green, DDS, MPH,
National Program for Playground Safety, IA Albany, NY; Steven Hadler, MD, Atlanta, GA; Meredith
Harris-Copp, EdD, Boston, MA; Terry S. Hatch, MD,
Joan Turetsky Champaign-Urbana, IL; Debra Hawks Peabody, MPH;
United States Department of Agriculture, VA Maxine Hayes, MD, Olympia, WA; Deborah Jackson;
Nancy Ellen Jones, PNP, DrPH, New York, NY; Karen
Juola, Topeka, KS; Dennis O. Juranek, DVM, MSc,
Elaine Tyrrell, MS Atlanta, GA; Brearley B. Karsch, MS, RD, Philadelphia,
U.S. Consumer Product Safety Commission, MD PA; Kay Kent, RN, Lawrence, KS; George Kupfer, MS,
Ann Arbor, MI; Edgar O. Ledbetter, MD, Elk Grove

xi Acknowledgments
Acknowledgments Caring for Our Children:
National Health and Safety Performance Standards

Village, IL; Dr. Darryl Leong, IA; Robert Lettelier, NH;

Kee MacFarlane, MSW, Los Angeles, CA; Kathleen Mal-
loy, MD, MPH, Martinez, CA; Pamela Mangu, MA,
Washington, DC; Valerie Marr, OK; Mary Ann Mateo,
Pine Hills, NM; Jack L. Mayer, MD, New York, NY; Mar-
cia K. McDonnell, MN, CANP, Atlanta, GA; Erick W.
Mood, MPH, New Haven, CT; Bliss Moore, MPH, RS,
Olympia, WA; Randolph S. Moore, MA; Linda Morgan,
MD, Lynn, MA; Geraldine Norris, RN, MS, Washington,
DC; Mary Ann O’Connor, MA, Hanover, NH; Michael
Osterholm, PhD, Minneapolis, MN; Karen Patjens, BA,
Tacoma, WA; Georges Peter, MD, Providence, RI; Marg-
aret Phillips, EdD, RD, Rockville, MD; Patricia M. Pierce,
PhD, Gainesville, FL; Ann Prendergast, MPH, RD, Rock-
ville, MD; Chris Pressey-Murray, Hanover, NH; Sally
Provence, MD, New Haven, CT; Linda Randolph, MD,
PHP, Albany, NY; Thomas A. Reardon, RS, Pasadena,
CA; Sally Reid, Esq, Dedham, MA; Cheri Robertson,
Temecula, CA; Martha Rodgers, MD, Atlanta, GA; Cris
Ros-Dukler, TX; Carol W. Runyan, PhD, Chapel Hill,
NC; Susan Russell, MS, Chapel Hill, NC; Hector
Sanchez, MSW, Washington, DC; Marion N. Scarbor-
ough, MPH, RD, Jacksonville, FL; Lawrence Schon-
berger, MD, MPH, Atlanta, GA; Ellen Schroth, RS,
Washington, DC; Ethel Seiderman, MA, Fairfax, CA;
Robert Shane, PhD, Wynnewood, PA; Cecil Sheps, MD,
MPH, Chapel Hill, NC; Sam Sheps, MD, Vancouver, BC,
Canada; Sallye Skipper Blake, EdS, Montgomery, AL;
Patricia St. Clair, RN, ScD, Seattle, WA; Jeanne Stell-
man, PhD, Brooklyn, NY; George Sterne, MD, New
Orleans, LA; Siubhan Stevens, San Jose, CA; Carol S.
Stevenson, JD, San Franscico, CA; Jack Thompson, Seat-
tle, WA; Jon Tillingheist, OK; Rosemary Totten, BA,
CDA, Tacoma, WA; Elaine Trate, Burke, VA; Key
Vaughn, RS, Austin, TX; Cynthia Vlasich, RN, Washing-
ton, DC; Patricia Wagner, EdD, Brooklyn, NY; Helen
Wallace, MD, MPH, San Diego, CA; Aileen Whitfill,
Arlington, VA; Mark Widome, MD, MPH, Hershey, PA;
Patricia Wise, RN, MEd, Holyoke, MA; Harry Wright,
Jr, MD, MPH, Los Angeles, CA; Clotilde Zayas, MA,
New York, NY.

Acknowledgments xii
Caring for Our Children: INTRODUCTION Introduction
National Health and Safety Performance Standards

INTRODUCTION for measuring what has been done and what still
needs to be done, as well as a technical manual on
In 1992, the American Public Health Asso- how to do it.
ciation (APHA) and the American Academy of
Pediatrics (AAP) jointly published Caring for Our The Maternal and Child Health Bureau’s funding, in
Children:.National Health and Safety Performance 1995, of a National Resource Center for Health
Standards: Guidelines for Out-of-Home Child Care Pro- and Safety in Child Care (NRC) at the University
grams.(1) The publication was the product of a 5- of Colorado Health Sciences Center School of
year national project funded by the U.S. Depart- Nursing supported the work to produce the new
ment of Health and Human Services Maternal and edition. The work plan included the following
Child Health Bureau (MCHB), Health Resources strategies:
and Services Administration. This comprehensive 1) Enjoin as many of the experts as possible who
set of health and safety standards was a response contributed to the first edition to participate
to many years of effort by advocates for quality in the revision effort;
child care. In 1976, Aronson and Pizzo recom- 2) Seek additional input from a national constitu-
mended development and use of national health ency of individuals and associations with vital
and safety standards as part of a report to Con- interest in the health and safety of children in
gress in association with the Federal Interagency out-of-home care;
Day Care Requirements (FIDCR) Appropriateness 3) Strive for national consensus through an itera-
Study.(1) In the years that followed, experts repeat- tive process of debate and discussion;
edly reaffirmed the need for these standards. For 4) Obtain approval and endorsement from the
example, while the work to prepare Caring for Our original developers, AAP, APHA, and the
Children was underway, the National Research MCHB.
Council's report, Who Cares for America’s Children?
Child Care Policy for the 1990s called for uniform The revision of the standards for the second edi-
national child care standards.(2) It is a privilege to tion of Caring for Our Children was an extensive
introduce the reader, in the year 2001, to the sec- process. The 10 technical panels focused on their
ond edition of Caring for Our Children. We will dis- particular subject matter areas, after which time
cuss why a new edition was deemed necessary, their recommendations were merged into a single
describe the process of revision, and highlight set of recommended standards and widely
some of the changes in the new standards. reviewed by representatives of all stakeholders
with an interest in child care, including parents.
The 1992 publication anticipated the new edition The final document represents a consensus of the
when it noted (that) "as new knowledge and inno- various disciplines involved with child care, with
vative practices evolve, the standards themselves the largest contribution of factual content coming
should be modified or updated.”(3) In the years from experts in health and safety.
since the first edition was published, the interest in
and the enrollment of young children in early The second edition benefited from the contribu-
childhood education programs has increased not tion of 55 newly engaged experts as well as that of
only in the United States but also in other nations a core group of veterans. The two co-chairs of the
in the world. The continuing requests for the hard Steering Committee (Susan S. Aronson, MD,
copy version and documented use of the elec- FAAP, and Albert Chang, MD, MPH, FAAP), eight
tronic version shows considerable interest by both of the 10 Technical Panel chairs, and the MCHB
a national and an international audience. Thus, the federal project officer (Phyllis Stubbs-Wynn, MD,
use of the standards since 1992 documents the MPH) were veterans from the first edition.
value of the standards and validates the use of Twenty-two out of 75 members of the Technical
resources required to keep the standards up-to- Panels were also veterans. Review and comments
date. Caring for Our Children has been a yardstick were received from 100 individuals from 65

xiii Introduction
Introduction Caring for Our Children:
National Health and Safety Performance Standards

stakeholder organizations representing providers, • Integration of standards that are relevant to

child care advocates, health professionals, safety children with special needs, as well as to all
specialists, early childhood educators, regulators, children, throughout the document to promote
and federal, military, and state agencies. A com- inclusion;
plete listing of the Steering Committee, Technical • A two-column format to increase readability
Panel members, and Stakeholder Organizations and eliminate empty space;
appears on the Acknowledgment pages. • Merged and consolidated standards (from 981
standards and recommendations to 707 stan-
The process of revising the standards and the con- dards and recommendations);
sensus building was organized in stages: • Expansion of the rationale and comment
1) Technical Panel Chairs recruited members to sections;
their panels and reviewed the standards from • Updated references;
the first edition. They removed standards that • Incorporation of former appendices into appro-
were no longer applicable or out-of-date, priate standards;
identified those that were still applicable (in • A more activist posture in standards pertaining
their original or in a revised form), and formu- to training requirements (for providers), health
lated new standards that were deemed appro- education activities (for providers, children, and
priate and necessary. parents), and management of acute illness (such
2) Telephone conference calls were convened as respiratory infections) and chronic illness
among technical panel chairs to bring consen- (such as asthma).
sus on standards that bridge several technical
areas. See Appendix A for the guiding principles used in
3) A draft of these revised standards was sent to writing these standards.
a national and state constituency of stakehold-
ers for their comments and suggestions. In projects of this scope and magnitude, the end
4) This feedback was subsequently reviewed and product is only as good as the persons who partic-
considered by the technical panels (often ipate in the effort. It is hard to enumerate in this
more than one) and a decision was made to introduction the countless hours of dedication and
further revise or not to revise a standard. It effort from contributors and reviewers. The
should be noted that the national review project owes each of them a huge debt of grati-
brought many important points of view and tude. Their reward will come when high-quality
new information for additional discussion and child care services become available to all children
debate. and their families!
5) The edited standards were then sent to desig-
nated review committees of the AAP and the Overlap with Requirements of Other
APHA. The funding agency, MCHB, also con- Organizations
ducted a concurrent review. Final copy was
approved by the Steering Committee repre- We recognize that many organizations have
senting the three organizations and the NRC. requirements and recommendations that apply to
out-of-home child care. For example, the National
The second edition contains eight chapters of 659 Association for the Education of Young Children
standards and a ninth chapter of 48 recommenda- (NAEYC) publishes requirements for
tions for licensing and community agencies and developmentally appropriate practice and
organizations. We have made the following signifi- accreditation of child care centers; Head Start
cant content and format changes in the second follows Performance Standards; the AAP has many
edition: standards related to child health; the Child
• New and revised standards in all areas, such as Welfare League of America has requirements for
sleep position of infants related to SIDS studies child care service; the U.S. Department of Defense
and playground equipment specifications;

Introduction xiv
Caring for Our Children: Introduction
National Health and Safety Performance Standards

has standards for military child care; the National personal-social skills. Thus, health and safety issues
Fire Protection Association has standards for fire overlap with those considered part of early child-
safety in child care settings. The Child Care hood education and mental health. Such overlap is
Bureau (CCB) administers the Child Care and inevitable and indeed desirable.
Development Fund (CCDF) which provides funds
to states, territories, and tribes to assist low- Continuing Improvement
income families, families receiving temporary
public assistance, and those transitioning from Standards are never static. Each year the knowl-
public assistance in obtaining child care so that edge base increases, and new scientific findings
they can work or attend training/education. Child become available. New areas of concern and inter-
care providers serving children funded by CCDF est arise. These standards will assist citizens who
must meet basic health and safety requirements are involved in the continuing work of standards
set by states and tribes. All of these are valuable improvement at every level: in child care practice,
resources, as are many excellent state in regulatory administration, and in the profes-
publications. By addressing health and safety as an sional performance of the relevant disciplines.
integrated component of child care, Caring for Our
Children complements these other child care Each of these areas affects the others in the ongo-
requirements and recommendations. ing process of improving the way we meet the
needs of children. Possibly the most important use
The concept of limiting child:staff ratio and group of these standards will be to raise the level of
size exemplifies this overlap. The NAEYC empha- understanding among the general public about
sizes the need for low infant:staff ratios for very what those needs are, and to contribute to a
young children to facilitate developmentally appro- greater willingness to commit more resources to
priate, warm, trusting and reciprocal relationships. achieve quality child care where children can grow
Having a few infants whose care is entrusted to a and develop in a healthy and safe environment.
limited number of adults in a setting where the
overall numbers of interactions is controlled by a Albert Chang MD, MPH, FAAP
small group size and a primary caregiving relation-
Susan S. Aronson MD, FAAP
ship helps develop the child’s trust and ability to
Co-Chairs, Steering Committee
make emotional attachments. Also, sufficient and
specific staff assignments are essential so caregiv-
ers know the status of each baby at all times; to be
sure that the baby is safe, to be able to evacuate REFERENCES:
that child and other children in the group in case (1)USHEW, Office of the Assistant Secretary for
of fire or other facility emergency, as well as to Planning and Evaluation. Policy Issues in Day care:
have sufficient time to practice and track health Summaries of 21 Papers. pp 109-115. 1977.
and safety routines, such as feedings and diaper
changing for each child. Caregivers in group child (2)National Research Council, National Academy
care settings perform the same demanding work
of Sciences. Who Cares for America's Children? Child
as parents of twins, triplets, or quadruplets.
Care Policy in the 1990s. Washington DC, 1990.
Health involves more than the absence of illness
American Public Health Association and Ameri-
(3)
and injury. To stay healthy, children depend on
can Academy of Pediatrics. Caring for Our Children.
adults to make healthy choices for them and to
National Health and Safety Performance Standards:
teach them to make such choices for themselves
Guidelines for Out-of-Home Child Care Programs.
over the course of a lifetime. Child development
Washington, DC, 1992.
addresses physical growth and the development in
many areas: gross and fine motor skills, language,
emotional balance, cognitive capacity, and

xv Introduction
 ADVISE TO USERS
Caring for Our Children: Advice to Users
National Health and Safety Performance Standards

DEFINITIONS individuals outside the organization. A recom-

mendation is not binding on the practitioner;
We have defined many terms in the Glossary that is, there is no obligation to carry it out. A
found on page 479. Some of these are so impor- statement may be issued as recommendation
tant to the user that we are emphasizing them because it addresses a fairly new topic or issue,
here as well. because scientific supporting evidence may not
yet exist, or because the practice may not yet
Types of requirements: Three terms describe dif- enjoy widespread acceptance by the members
ferent types of requirements have been carried of the organization or by the intended audience
forward from the 1992 edition: for the recommendation.

• A standard is a statement that defines a goal of For example, in Chapter 9 of Caring for Our Chil-
practice. It differs from a recommendation or a dren, Recommendation 9.004 suggests that
guideline in that it carries great incentive for uni- States should adopt uniform categories and defi-
versal compliance. It differs from a regulation in nitions for use in their own licensing that cover
that compliance is not necessarily required for the types of facilities addressed by the stan-
legal operation. It usually is legitimized or vali- dards. While it is recognized that each State
dated based on scientific or epidemiological might differ in the specific definitions of services
data, or when this evidence is lacking, it repre- they choose to use, the recommendation says
sents the widely agreed upon, state-of-the-art, that each State should be sure that the sum of
high-quality level of practice. their licensing effort should address all the types
of service specified in the standards.
The agency, program, or health practitioner that
does not meet the standard may incur disap- • A guideline is a statement of advice or
proval or sanctions from within or outside the instruction pertaining to practice. Like a
organization. Thus, a standard is the strongest recommendation, it originates in an organization
criteria for practice set by a health organization with acknowledged professional standing.
or association. For example, many manufactur- Although it may be unsolicited, a guideline is
ers advertise that their products meet ASTM developed in response to a stated request or
standards as evidence to the consumer of safety, perceived need for such advice or instruction.
while those products that cannot meet the stan- For example, the American Academy of
dards are sold without such labeling to undis- Pediatrics (AAP) has a guideline for the
cerning purchasers. In Caring for Our Children, elements required to make the diagnosis of
specific standards define the frequency of visits Attention-Deficit/Hyperactivity Disorder.
to child care facilities and qualifications of health
consultants to such facilities. Some states have • A regulation takes a previous recommendation
adopted or even exceeded parts of these stan- or guideline and makes it a requirement for legal
dards in their regulations, but many more have operation. A regulation originates in an agency
not done so. Facilities that use a health consult- with either governmental or official authority
ant, as specified in Standards 1.040 through and has the power of law. Such authority is
1.044, could be expected to be of higher quality usually accompanied by an enforcement activity.
than those that do not. Examples of regulations are: State regulations
pertaining to health and safety requirements for
• A recommendation is a statement of practice caregivers and children in a licensed child care
that potentially provides a health benefit to the center, and immunizations required for
population served. An organization or a group participation in group care. The components of
of individuals with expertise or broad experi- the regulation, of course, will vary by topic
ence in the subject matter usually initiates it. It addressed as well as by area of jurisdiction (e.g.,
may originate within the group or be solicited by municipality or state). Because a regulation

xvii Advice to Users

Advice to Users Caring for Our Children:
National Health and Safety Performance Standards

prescribes a practice that every agency or qualified adult assistants so that the require-
program must comply with, it usually is the ments specified in the child:staff ratio and group
minimum or the floor below which no agency or size standard are met. The key element that dis-
program should operate. tinguishes this type of facility is the combined
use of the premises as a residence and for child
Types of facilities: Child care offers developmen- care (often simultaneously) and that the number
tal care and education for children who live at of children in care requires more than one care-
home with their families. Several types of facilities giver present at any one time.
are covered by the general definition of child care.
Although States vary greatly in their legal defini- • A Center is a facility that provides care and edu-
tions, overall, there is a generally understood defi- cation to any number of children in a nonresi-
nition for child care facilities. Much overlap and dential setting, or 13 or more children in any
confusion of terms still exists in defining child care setting, if the facility is open on a regular basis.
facilities. Although the needs of children do not To distinguish a child care center from drop-in
differ from one setting to another, the declared facility, a center usually provides care for some
intent of different types of facilities may differ. children for more than 30 days per year per
Thus, facilities that operate part-day, in the child. In many cases, summer camps operate for
evening, during the traditional work day and work more 30 days per year per child and, in fact,
week, or during a specific part of the year may call provide center-based child care.
themselves by different names. These standards
recognize that while children’s needs do not differ • A Drop-in-Facility provides care for fewer than
in any of these settings, the way children’s needs 30 days per year per child either on a consecu-
are met may differ by whether the facility is in a tive or intermittent basis or on a regular basis,
residence or a non-residence and whether the but for a series of different children.
child is expected to have a longer or only a very
short-term arrangement for care. Thus, we have • A School-Age Child Care Facility offers activi-
designated the type of facility to which each stan- ties to children before and after school, during
dard applies using the following definitions: vacations, and on non-school days set aside for
such activities as teachers’ in-service programs.
• A Small Family Child Care Home provides
care and education for up to six children at one • A Facility for Children with Special Needs
time, including the preschool children of the provides specialized care and education for
caregiver, in a residence that is usually, but not children who cannot be accommodated in a set-
necessarily, the home of the caregiver. The key ting with typically developing children.
elements are that this type of care takes place in
a setting that is used both for child care and as a • A Facility for Ill Children provides care for one
residence (often simultaneously) and that the or more children who are temporarily excluded
total number of children is limited to a maxi- from care in their regular child care setting.
mum of six at any one time. Family members or Their condition does not require parental care
other helpers may be involved in assisting the but they cannot participate in the regular pro-
caregiver, but often, there is only one caregiver gram at their usual source of child care, require
present at any one time. more staff time than can be offered in their
usual setting without putting the other children
• A Large Family Child Care Home provides at risk, or have a condition that poses a risk for
care and education for between 7 and 12 child- the adults or children in their usual child care
ren at a time, including the preschool children of facility. Such facilities for ill children are of two
the caregiver, in a residence that is usually, but types:
not necessarily, the home of one of the caregiv-
ers. Staffing of this facility involves one or more

Advice to Users xviii

Caring for Our Children: Advice to Users
National Health and Safety Performance Standards

• An Integrated or Small Group Care lished elsewhere, that reference is cited. Refer-
Facility for Ill Children provides care ences for the rationales are at the end of each
that has been approved by the licensing chapter. Thus, the rationales both justify the stan-
agency in a facility that cares for well dard and serve as an educational tool. The Com-
children and is authorized to include up to ments section includes other explanatory
six ill children. information relevant to the standard, such as appli-
cability of the standard and, in some cases, sug-
• A Special Facility for Ill Children cares
gested ways to measure compliance with the
only for ill children or cares for more than
standard. Although this document reflects the best
six ill children at a time.
information available at the time of publication, like
the first edition, this second edition will need
Age groups: Although we recognize that desig-
updating from time to time to reflect changes in
nated age groups and developmental levels must
knowledge affecting child care.
be used flexibly to meet the needs of individual
children, many of the standards are applicable to
Because the standards have many users with differ-
specific age and developmental categories. The fol-
ing backgrounds and need for reference material,
lowing categories are used in Caring for Our
we ask readers of Caring for Our Children to accept
Children.
some inconvenience when their purpose might be
better met by a different format. The electronic
version will help users to search for key words and
Develop- Age Functional Definition (By concepts that might be addressed in a variety of
mental Developmental Level) places in the document. Although the standards
Stage have not been written from the perspective of a
Infant 0-12 Birth to ambulation single use, we expect that many of the standards
months will be used as licensing requirements. Therefore,
Toddler 13-35 Ambulation to accom- to the extent possible, the wording of the stan-
months plishment of self-care dards has been written to be measurable and
routines such as use of enforceable. Also, measurability is important for
the toilet performance standards in a contractual relation-
ship between a provider of service and a funding
Pre- 36-50 From achievement of self- source. Concrete and specific language helps care-
schooler months care routines to entry givers and facilities put the standards into practice.
into regular school Where a standard is difficult to measure, we have
School- 5-12 Entry into regular school, provided guidance to make the requirement as
Age Child years including kindergarten specific as possible. For some readers, the wording
through 6th grade of some standards may seem highly technical; they
will need to have that standard interpreted by spe-
cialists. Whenever feasible, we have written the
Format and Language Level standards to be understood by readers from a
wide variety of backgrounds.
In Chapters 1 through 8, the reader will find the
scientific reference and/or epidemiological evi-
dence for the standard in the rationale section of Users of the Standards
each standard. The rationale explains the intent of
and the need for the standard. Where no scientific The intended users of the standards include many
evidence for a standard is available, the standard is who contribute to the well-being of children. Each
based on the best available professional consensus. has a unique viewpoint. For many of the users,
If such a professional consensus has been pub- access to the Internet version of the publication
will be useful. For those who need a full print

xix Advice to Users

Advice to Users Caring for Our Children:
National Health and Safety Performance Standards

document, the hard copy will be preferable. Many 3. As guidance to citizens' groups in states
will want to use both versions for different revising their licensing requirements:
purposes. For example, the electronic search of Because licensing has the force of law, care-
the Internet version helps identify all points in the givers and facilities must meet any require-
standards that address a particular topic. The hard ments set by licensing agencies. Resource
copy is easily used where Internet access is limitations may delay full implementation of
unavailable. The intended users include: some of the standards. To address such limi-
• Health professionals tations, the Maternal and Child Health
• Trainers Bureau funded a project to set priorities
• Regulators among the standards based on their associa-
• Child Care Providers tion with the prevention of disease, disabil-
• Academics and Researchers ity and death (morbidity and mortality). The
publication of this subset of the first edition
All of the standards are attainable. Some may have of Caring for Our Children was called Stepping
already been attained in individual settings; others Stones to Using Caring for Our Children.
can be implemented over time. For example, any Where resource constraints require
organization that funds child care should, in our focused implementation, the updated stan-
opinion, adopt these standards as funding require- dards that correspond with Stepping Stones
ments and should set a payment rate that covers should be the first implemented. A similar
the cost of meeting them. process must be used to look at the new
standards that first appear in the second
The following are some of the ways in which edition.
Caring for Our Children may be used:
4. As guidance material to State Depart-
1. As guidance material for administrators ments of Education (DOEs) and local
and caregivers: Anyone operating a child school administration: Some public
care facility on any level needs information schools and private schools offer programs
on good practice. These standards will for 4-year-olds and even younger children.
inform: A few schools provide infant programs.
• Administrators at all levels, from those Licensing requirements for child care sel-
who operate a chain of centers to caregiv- dom cover public and private school sys-
ers in small family child care homes tems. Few States have written standards for
• Caregivers such programs when they are operated by
• Those who teach courses to caregivers. schools. Many school codes fail to ade-
quately address child handwashing, location
2. As a reference for consultants: Public of bathrooms, child:staff ratios and group
health professionals, pediatricians, and oth- size, teacher qualifications for working with
ers provide consultation to caregivers. This preschool children, and injury prevention.
role requires knowledge that goes beyond As state DOEs begin to write standards for
traditional patient-centered pediatrics or school-operated child care and preschool
public health approaches. Many local and facilities, and as principals begin to imple-
state health departments have developed ment good practice in early childhood and
child care guidance material that public child care facilities, this guidance material
health nurses, sanitarians, and nutritionists, will help.
among others, use in consulting with care-
givers. This document will help support
and update such guidance material.

Advice to Users xx
Caring for Our Children: Advice to Users
National Health and Safety Performance Standards

5. As guidance material for funding of sub- 7. As guidance material for parents and the
sidized facilities: Most States and localities general public: Parents need consumer
provide child care services for income-eligi- information to choose quality child care for
ble families through purchase-of-service their children. By drawing on the standards,
contracts and individual vendor/voucher organizations that serve parents can train
mechanisms. Public interest in purchasing their staff and develop educational materials
child development services for at-risk child- that provide credentialed advice for parents.
ren has increased, largely due to dissemina- For example, resource and referral counse-
tion of research about the key role played lors, community health professionals, and
by early childhood experience in the devel- social workers will be able to use Caring for
opment of the brain. Welfare-to-work poli- Our Children as a reference for their work
cies have increased attention to the use of with parents, the general public, and the
non-parental child care by the poor that media.
parallels increased interest in child care for
middle and upper class families as more
women in all groups are participating in the Relationship of the Standards to Laws,
labor force. Ordinances, and Regulations
Many communities offer subsidized child The members of the technical panels could not
care/developmental services for children annotate the standards to address local laws,
with special needs. Schools and other agen- ordinances, and regulations. Many of these legal
cies are setting up specialized arrangements requirements are out-of-date or have a different
to serve children with special needs, some- intent from that addressed by the standards. Users
times paying for children with special needs of this document should check legal requirements
to be included in local community child care that may apply to facilities in particular locales.
settings with typically developing children. Where conflicts are noted, we recommend
When States and localities purchase child further work at the local level to resolve such
care services, the standards offer guidance conflicts.
not only on the level of service to expect,
but also a way to estimate the correspond- In general, child care is regulated by at least three
ing level of funding to meet such require- different legal entities or jurisdictions. The first is
ments for children with special needs. the building code jurisdiction. Building inspectors
enforce building codes to protect life and property
6. As guidance material to other national in all buildings, not just child care facilities. Some of
private organizations that write the recommended standards should be written
standards: Several other national into state or local building codes, rather than into
organizations have expressed their strong the licensing requirements.
interest in child care by writing standards
for accreditation or guidance for the field. The second major legal entity that regulates child
Both the first and second editions of Caring care is the health system. A number of different
for Our Children draw on the expertise of codes are intended to prevent the spread of dis-
these other organizations in developing the ease in restaurants, hospitals, and other institu-
standards. Reciprocally, the work done on tions where hazards and risky practices might
these standards should be equally useful to exist. Many of these health codes are not specific
other organizations. to child care; however, specific provisions for child

xxi Advice to Users

Advice to Users Caring for Our Children:
National Health and Safety Performance Standards

care might be found in a health code. Some of the

provisions in the recommended standards might
be appropriate for incorporation into a health
code.

The third legal jurisdiction applied to child care is

child care licensing. Usually, before a child care
operator receives a license, the operator must
obtain approvals from health and building safety
authorities. Sometimes a standard is not included
as a child care licensing requirement because it is
covered in another code. Sometimes, however, it
is not covered in any code. Since children need full
protection, the issues addressed in this document
should be addressed in some aspect of public pol-
icy, and consistently addressed within a commu-
nity. In an effective regulatory system, different
inspectors do not try to regulate the same thing.
Advocates should decide which codes to review in
making sure that these standards are addressed
appropriately in their regulatory systems.
Although the licensing requirements are most usu-
ally affected, it may be more appropriate to revise
the health or building codes to include certain
standards and it may be necessary to negotiate
conflicts among applicable codes.

Advice to Users xxii

 CHAPTER 1

CHAPTER 1: Staffing

Staffing
Caring for Our Children:
National Health and Safety Performance Standards

1.1 CHILD:STAFF RATIO AND interactions are correlated with lower child:staff
ratios (3). For 3- and 4-year old children, the size of
GROUP SIZE the group is even more important than ratios. The
recommended group size and child:staff ratio allow 3-
to 5- year old children to have continuing adult sup-
STANDARD 1.001 port and guidance while encouraging independent,
RATIOS FOR SMALL FAMILY CHILD self-initiated play and other activities (4).
CARE HOMES
The National Fire Protection Association (NFPA)
The small family child care home provider requires in the NFPA-101 Life Safety Code that small
child:staff ratios shall conform to the following
table: family child care homes serve no more than 2 clients
incapable of self-preservation (6).

COMMENTS: Some states are setting limits on the

If the small family then the small family
child care home child care home number of school-age children that are allowed to be
provider has no provider may have 1- cared for in small family child care homes, e.g., two
children under two 6 children over two school-age children in addition to the maximum num-
years of age in care, years of age in care ber allowed for infants/preschool children. No data
are available to support using a different ratio where
If the small family then the small family school-age children are in family child care homes.
child care home child care home
provider has 1 child provider may have 1- Since school-age children require focused caregiver
under two years of 3 children over two time and attention for supervision and adult-child
age in care, years of age in care interaction, this standard applies the same ratio to all
children over two years of age. The family child care
If the small family then the small family provider must be able to have a positive relationship
child care home child care home and provide guidance for each child in care.
provider has 2 provider may have no
children under two children over two
years of age in care, years of age in care Unscheduled inspections encourage compliance with
this standard.

For more information regarding brain development in

The small family child care home provider's own children in child care, see STANDARD 1.010.
children shall be included in the child:staff ratio.
TYPE OF FACILITY: Small Family Child Care Home
RATIONALE: Although child:staff ratios alone do not
predict the quality of care, direct warm social interac-
tion between adults and children is more common STANDARD 1.002
and more likely with lower child:staff ratios. Care - RATIOS FOR LARGE FAMILY CHILD
givers must be recognized as performing a job for CARE HOMES AND CENTERS
groups of children that parents of twins, triplets, or
quadruplets would rarely be left to handle alone. In Child:staff ratios in centers and large family child
child care, these children do not come from the same care homes shall be maintained as follows during
family and must learn a set of common rules that may all hours of operation, including transport and nap
differ from expectations in their own homes. times:

Low child:staff ratios are most critical for infants and During nap time, at least one adult shall be physi-
young toddlers (0 to 24 months) (1). Infant develop- cally present in the same space as the children.
ment and caregiving quality improves when group size
and child:staff ratios are smaller (2). Improved verbal

3 Chapter 1: Staffing
 Caring for Our Children:
National Health and Safety Performance Standards

Maximum Maximum sizes recommended in the National Research Coun-

Age Child:Staff Group Size cil's report, Who Cares for America's Children? Child
Ratio Care Policy for the 1990s (1). According to the
National Research Council, child:staff ratios and
Birth - 12 3:1 6 group size are two of the four most important areas
mos. to be addressed in national standards.
13 - 30 mos. 4:1 8
31 - 35 mos. 5:1 10 Children with special health care needs may require
3-year-olds 7:1 14 additional staff on-site, depending on their special
need and extent of disability (1).
4-year-olds 8:1 16
5-year-olds 8:1 16 Low child:staff ratios for non-ambulatory children are
6 - 8-year- 10:1 20 essential for fire safety. The National Fire Protection
olds Association, in its NFPA-101 Life Safety Code, recom-
9 - 12-year- 12:1 24 mends that no more than three children younger than
olds 2 years of age be cared for in large family child care
homes where two staff members are caring for up to
Other adults who are included in the child:staff 12 children (6).
ratio need not be in the same space with the child-
ren when all the children are napping. However, in Children benefit from social interactions with peers.
case of emergency, these adults shall be on the However, larger groups are generally associated with
same floor and shall have no barrier to their com- less positive interactions and developmental out-
ing to help immediately. The caregiver who is in comes. Group size and ratio of children to adults are
the same space with the children shall be able to limited to allow for one to one interaction, intimate
summon these adults without leaving the children. knowledge of individual children, and consistent care-
giving (7).
When there are mixed age groups in the same
room, the child:staff ratio and group size shall be
consistent with the age of most of the children Although child:staff ratios alone do not predict the
when no infants or toddlers are in the mixed age quality of care, direct warm social interaction
group. When infants or toddlers are in the mixed between adults and children is more common and
age group, the child:staff ratio and group size for more likely with lower child:staff ratios. Caregivers
infants and toddlers shall be maintained. In large must be recognized as performing a job for groups of
family child care homes with two or more care- children that parents of twins, triplets, or quadruplets
givers caring for no more than 12 children, no would rarely be left to handle alone. In child care,
more than three children younger than 2 years of these children do not come from the same family and
age shall be in care. must learn a set of common rules that may differ from
expectations in their own homes.
RATIONALE: These child:staff ratios are within the
range of recommendations for each age group that
Low child:staff ratios are most critical for infants and
the National Association for the Education of Young
young toddlers (0 to 24 months) (1). Infant develop-
Children (NAEYC) uses in its accreditation program
ment and caregiving quality improves when group size
(5). The NAEYC recommends a range that assumes
and child:staff ratios are smaller (2). Improved verbal
the director and staff are highly trained and, by virtue
interactions are correlated with lower ratios (3). For
of the accreditation process, has determined a staffing
3- and 4-year old children, the size of the group is
pattern that enables effective staff function. The stan-
even more important than ratios. The recommended
dard for child:staff ratios in this document uses a sin-
group size and child:staff ratio allow 3- to 5- year old
gle desired ratio, rather than a range, for each age
children to have continuing adult support and guid-
group. In some cases, these child:staff ratios and
ance while encouraging independent, self-initiated play
group sizes are the more stringent ratios and group
and other activities (4).

Chapter 1: Staffing 4
Caring for Our Children:
National Health and Safety Performance Standards

In addition, the children's physical safety and sanita- work environment for caregivers. Community
tion routines require a staff that is not fragmented by resources other than parent fees and a greater public
excessive demands. Child:staff ratios in child care set- investment in child care are critical to achieving the
tings should be sufficiently low to keep staff stress child:staff ratios and group sizes specified in this
below levels that might result in anger with children. standard.
Caring for too many young children, in particular,
increases the possibility of stress to the caregiver, and For more information regarding brain development in
may result in loss of self-control. children in child care, see STANDARD 1.010.

Although observation of sleeping children does not TYPE OF FACILITY: Center; Large Family Child Care
require the physical presence of more than one care- Home
giver, the staff needed for an emergency response or
evacuation of the children must remain available for
this purpose. Nap time may be the best option for STANDARD 1.003
regular staff conferences and staff training, but these RATIOS FOR FACILITIES SERVING
activities should take place in an area next to the CHILDREN WITH SPECIAL HEALTH
room where the children are sleeping so no barrier NEEDS
will prevent the staff from assisting if emergency evac-
uation becomes necessary. Facilities enrolling children with special needs shall
determine, by an individual assessment of each
COMMENTS: The child:staff ratio indicates the maxi- child’s needs, whether the facility requires a lower
mum number of children permitted per caregiver (8). child:staff ratio.
These ratios assume that caregivers do not have time-
consuming bookkeeping and housekeeping duties, so RATIONALE: The child:staff ratio must allow the
they are free to provide direct care for children. The needs of the children enrolled to be met. The facility
ratios do not include other personnel (such as bus should have sufficient direct care professional staff to
drivers) necessary for specialized functions (such as provide the required programs and services. Inte-
driving a vehicle). grated facilities with fewer resources may be able to
serve children who need fewer services, and the staff-
Group size is the number of children assigned to a ing levels may vary accordingly. Adjustment of the
caregiver or team of caregivers occupying an individ- ratio allows for the flexibility needed to meet the
ual classroom or well-defined space within a larger child’s type and degree of special need. The facility
room (8).The "group" in child care represents the should seek consultation with parents and other pro-
"homeroom" for school-age children. It is the psycho- fessionals regarding the appropriate child:staff ratio
logical base with which the child identifies and from and may wish to increase the number of staff mem-
which the child gains continual guidance and support bers if the child requires significant special assistance.
in various activities. This standard does not prohibit
larger numbers of children from joining in collective COMMENTS: These ratios do not include personnel
activities as long as child:staff ratios and the concept who have other duties that might preclude their
of "home room" are maintained. involvement in needed supervision while they are per-
forming those duties, such as cooks, maintenance
Unscheduled inspections encourage compliance with workers, or bus drivers.
this standard.
TYPE OF FACILITY: Center; Large Family Child Care
These standards are based on what children need for Home: Small Family Child Care Home
quality nurturing care. Those who question whether
these ratios are affordable must consider that our
efforts to limit costs have resulted in overlooking the
basic needs of children and creating a highly stressful

5 Chapter 1: Staffing
 Caring for Our Children:
National Health and Safety Performance Standards

STANDARD 1.004 children suggest that requirements and environmental

RATIOS DURING TRANSPORTATION modifications will reduce the risk for this type of
injury. Essential elements are close continuous
Child:staff ratios established for out-of-home child supervision (9), fences and self-locking gates around
care shall be maintained on all transportation the all swimming/wading pools, hot tubs, and spas, and
facility provides or arranges. The driver shall not special safety covers on pools when they are not in
be included in the ratio. No child of any age shall use (10). Infant swimming programs have led to water
be left unattended in a vehicle. intoxication and seizures because infants may swallow
excessive water when they are engaged in any
RATIONALE: Children must continue to receive ade- submersion activities.
quate supervision during transport. Placement of a
child in a vehicle does not eliminate the need for
COMMENTS: These ratios do not include personnel
supervision.
who have other duties that might preclude their
involvement in supervision during swimming/wading
Drivers must not be distracted from safe driving prac-
activities while they are performing those duties.
tices by being simultaneously responsible for the
Thus, this ratio excludes cooks, maintenance work-
supervision of children.
ers, or lifeguards from being counted in the child:staff
ratio if they are involved in these specialized duties at
TYPE OF FACILITY: Center; Large Family Child Care
the same time. A lifeguard is not counted in the
Home; Small Family Child Care Home
child:staff ratio unless he/she is assigned only to the
children in that group.
STANDARD 1.005 TYPE OF FACILITY: Center; Large Family Child Care
RATIOS FOR WADING AND Home; Small Family Child Care Home
SWIMMING
The following child:staff ratios shall apply while
children are wading or swimming: 1.2 LICENSURE/CERTIFICATION
OF QUALIFIED INDIVIDUALS
Child:Staff
Developmental Levels
Ratio STANDARD 1.006
Infants 1:1 CHILD CARE CREDENTIAL
Toddlers 1:1 Any individual who will be primarily responsible
Preschoolers 4:1 for children in a separate classroom, a group of
School-age Children 6:1 children, or a small family child care home shall
hold an official child care credential as granted by
the authorized state agency.
During any swimming/wading activity involving
mixed developmental levels where either an infant RATIONALE: The supervision of children must be
or a toddler is present, the ratio shall always be 1
adult to 1 infant/toddler. The required ratio of overseen by a person who has experience and educa-
adults to older children shall be met without tion to properly care for them. The qualification of
including the adults who are required for supervi- anyone who will be alone with children must be
sion of infants and/or toddlers. An adult shall actively assured and not assumed.
remain in direct physical contact with infants at all
times during swimming or wading. TYPE OF FACILITY: Center; Large Family Child Care
Home; Small Family Child Care Home
RATIONALE: The circumstances surrounding
drownings and water-related injuries of young

Chapter 1: Staffing 6
Caring for Our Children:
National Health and Safety Performance Standards

1.3 PRESERVICE COMMENTS: Reasons to deny employment include

the following:
QUALIFICATIONS AND 1) The applicant or employee is not qualified or is
SPECIAL TRAINING unable to perform the essential functions of the
job with or without reasonable accommodations;
GENERAL QUALIFICATIONS FOR 2) Accommodation is unreasonable or will result in
ALL CAREGIVERS, INCLUDING undue hardship to the program;
DIRECTORS, OF ALL TYPES OF 3) The applicant's or employee's condition will pose a
significant threat to the health or safety of that
FACILITIES individual or of other staff members or children.

Accommodations and undue hardship are defined and

STANDARD 1.007 based on each individual situation.
STAFF RECRUITMENT
Caregivers can obtain copies of the Equal Employ-
Staff recruitment shall be based on a policy of non-
discrimination with regard to gender, race, ethnic- ment Opportunity Act and the American with Dis-
ity, disability, or religion, as required by the Equal abilities Act from their local public library (11, 12).
Employment Opportunity Act. The policy of non- Facilities should consult with ADA experts through
discrimination shall extend also to sexual orienta- the U.S. Department of Education funded Disability
tion. Staff recruitment policies shall adhere to and Business Technical Assistance Centers through-
requirements of the Americans with Disabilities out the country. These centers can be reached by
Act as it applies to employment. The tasks calling 1-800-949-4232 and callers will be routed to
required for each position shall be defined in writ- the appropriate region.
ing and the suitability of an applicant shall be mea-
sured with regard to the applicant’s qualifications TYPE OF FACILITY: Center; Large Family Child Care
and abilities with the tasks required in the role. Home; Small Family Child Care Home
RATIONALE: Child care providers must adhere to
federal law. In addition, child care providers should
model diversity and non-discrimination in their STANDARD 1.008
employment practices to enhance the quality of the REFERENCES AND BACKGROUND
program and to teach children and parents about CHECKS
diversity and tolerance for individuals on the staff who
are competent caregivers with different background Directors of centers and caregivers in large and
and orientation in their private lives. small family child care homes shall check refer-
ences and examine employment history and crimi-
nal and other appropriate court records (including
The goal of the Americans with Disabilities Act fingerprinting and checks with state child abuse
(ADA) in employment is to reasonably accommodate registries) before employing any staff member
applicants and employees with disabilities to provide (including substitutes), even in states where licens-
them equal employment opportunity and to integrate ing has not been instituted. Background checks
them into the program's staff to the extent feasible, shall be required for all child care providers.
given the individual's limitations. Under the ADA,
employers are expected to make reasonable accom- When checking references, prospective employers
modations for persons with disabilities. Some disabili- shall specifically ask about previous convictions
ties may be accommodated, whereas others may not with child abuse or child sexual abuse. Failure of
allow the person to do essential tasks. The fairest way the prospective employee to disclose previous
to address this evaluation is to define the tasks and
convictions of child abuse or child sexual abuse is
grounds for dismissal.
measure the abilities of applicants to perform them.

7 Chapter 1: Staffing
 Caring for Our Children:
National Health and Safety Performance Standards

Persons who acknowledge being sexually attracted All directors and caregivers shall document receipt
to children or who acknowledge having physically of training that revisits the following topics every 3
or sexually abused children, or who are known to years:
have committed such acts shall not be hired or a) Child development knowledge and best prac-
allowed to work in the child care facility. tice, including knowledge about the develop-
mental stages of each child in care;
RATIONALE: To ensure their safety and physical and b) Child care as a support to parents;
mental health, children must be protected from any c) Parent relations;
risk of abuse. Although few persons will acknowledge d) Ways that communicable diseases are spread;
past child abuse to another person, the obvious atten- e) Procedures for preventing the spread of com-
tion directed to the question by the licensing agency municable disease, including handwashing, san-
or caregiver may discourage some potentially abusive
itation, diaper changing, food handling, health
department notification of reportable dis-
individuals from seeking employment in child care. In eases, equipment, toy selection and proper
addition, the measure is very inexpensive. washing, sanitizing to reduce the risk for dis-
ease and injury, and health issues related to
COMMENTS: Records of substantiated child abuse having pets in the facility;
are usually kept in state social services departments. f) Immunization requirements for children and
staff, as defined in STANDARD 1.045;
In the State of California, a state supported service g) Common childhood illnesses and their
for facilitating background checks has been successful management, including child care exclusion
in identifying people applying for child care jobs who policies;
have a history of previous offenses against children. h) Organization of the facility to reduce the risks
for illness and injury;
i) Teaching child care staff and children about
Child care centers with multiple caregivers are more infection control and injury prevention;
likely to protect children from abuse than child care j) Staff occupational health and safety practices,
sites where there is only one caregiver. Therefore, such as proper procedures, in accordance
this standard must be applied to caregivers who work with Occupational Safety and Health Adminis-
in isolation. tration (OSHA) bloodborne pathogens regula-
tions;
TYPE OF FACILITY: Center; Large Family Child Care k) Emergency procedures, as defined in
Home; Small Family Child Care Home STANDARD 3.048 through STANDARD
3.052;
l) Promotion of health in the child care setting,
through compliance with STANDARD 3.001
STANDARD 1.009 through STANDARD 3.089;
PRESERVICE AND ONGOING STAFF m) Management of a blocked airway, rescue
TRAINING breathing, and other first aid procedures, as
required in SSTANDARD 1.026;
In addition to the credentials listed in STANDARD n) Recognition and reporting of child abuse in
1.014, prior to employment, a director of a center compliance with state laws;
or a small family child care home network enroll- o) Nutrition;
ing 30 or more children shall provide documenta- p) Knowledge of medication administration poli-
tion of at least 26 clock hours of training in health, cies and practices;
psychosocial, and safety issues for out-of-home q) Caring for children with special needs in com-
child care facilities. pliance with the Americans with Disabilities
Act (ADA);
Small family child care home providers shall pro- r) Behavior management.
vide documentation of at least 12 hours of training
in child development and health management for RATIONALE: The director of a center or large family
out-of-home child care facilities prior to initiating child care home or the small family child care home
operation. provider is the person accountable for all policies.

Chapter 1: Staffing 8
Caring for Our Children:
National Health and Safety Performance Standards

Basic entry-level knowledge of health and safety is STANDARD 1.010

essential to administer the facility. Caregivers must be ADDITIONAL QUALIFICATIONS FOR
knowledgeable about infectious disease because prop- CAREGIVERS SERVING CHILDREN
erly implemented health policies can reduce the BIRTH TO 35 MONTHS OF AGE
spread of disease, not only among the children but
also among staff members, family members, and in the Caregivers shall be prepared to work with infants
greater community. Knowledge of injury prevention and toddlers and, when asked, shall be knowledge-
measures in child care is essential to control known able and demonstrate competency in tasks associ-
risks. Pediatric first aid training is important because ated with caring for infants and toddlers:
the director or small family child care home provider a) Diapering;
is fully responsible for all aspects of the health of the b) Bathing;
children in care.
c) Feeding;
d) Holding;
e) Comforting;
COMMENTS: The American Academy of Pediatrics f) Putting babies down to sleep positioned on
(AAP) and the National Association for the Education their backs and on a firm surface to reduce the
of Young Children (NAEYC) published a set of videos, risk of Sudden Infant Death Syndrome (SIDS);
based on the first edition of Caring for Our Children, g) Providing responsive and continuous interper-
that illustrates how to meet the standards in centers sonal relationships and opportunities for child-
and family child care homes. This six-part video series initiated activities.
is accompanied by a set of reproducible handouts for
training. Other training materials, including videos, To help manage atypical or disruptive behaviors of
workshop curricula, and print materials suitable for children, caregivers, in collaboration with parents,
training of caregivers, are also available from the AAP
shall seek professional consultation from the
child's source of routine health care or a mental
and NAEYC. Contact information for the AAP and health professional.
the NAEYC is located in Appendix BB.
RATIONALE: The brain development of infants is par-
Training in infectious disease control and injury pre- ticularly sensitive to the quality and consistency of
vention is strongly recommended. This type of train- interpersonal relationships. Much of the stimulation
ing may be obtained from qualified personnel of for brain development comes from the responsive
children’s and community hospitals, managed care interactions of caregivers and children during daily
companies, health agencies, public health depart- routines. Children need to be allowed to pursue their
ments, pediatric emergency room physicians, or other interests and encouraged to reach for new skills (13).
health professionals in the community.
COMMENTS: For additional qualifications and
For more information about training opportunities, responsibilities of teachers for centers and homes
contact the AAP, Healthy Child Care America Project, serving children from birth to 35 months, see also
the National Resource Center for Health and Safety General Qualifications for All Caregivers,
in Child Care, or the National Training Institute for STANDARD 1.007 through STANDARD 1.010; and
Child Care Health Consultants (at the University of Training, STANDARD 1.023 through STANDARD
North Carolina). Contact information is located in 1.036.
Appendix BB.
TYPE OF FACILITY: Center; Large Family Child Care
TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home
Home; Small Family Child Care Home

9 Chapter 1: Staffing
 Caring for Our Children:
National Health and Safety Performance Standards

STANDARD 1.011 TYPE OF FACILITY: Center; Large Family Child Care

ADDITIONAL QUALIFICATIONS FOR Home; Small Family Child Care Home
CAREGIVERS SERVING CHILDREN 3
TO 5 YEARS OF AGE
STANDARD 1.012
Caregivers shall demonstrate the ability to apply ADDITIONAL QUALIFICATIONS FOR
their knowledge and understanding of the follow- CAREGIVERS SERVING SCHOOL-
ing, to children within the program setting: AGE CHILDREN
a) Typical and atypical development of 3- to 5-
year-old children; Caregivers shall demonstrate knowledge about
b) Social and emotional development of children, and competence with the social and emotional
including children's development of indepen- needs and developmental tasks of 5- to 12-year
dence and their ability to adapt to their envi- old children, be able to recognize and appropri-
ronment and cope with stress; ately manage difficult behaviors, and know how to
c) Cognitive, language, early literacy, and mathe- implement a socially and cognitively enriching pro-
matics development of children through activi- gram that has been developed with input from
ties in the classroom; parents.
d) Cultural backgrounds of the children in the
facility's care by demonstrating cultural com- To help manage atypical or disruptive behaviors of
petence through interactions with children children, caregivers, in collaboration with parents,
and families and through program activities. shall seek professional consultation from the
child’s source of routine health care or a mental
To help manage atypical or disruptive behaviors of health professional.
children, caregivers, in collaboration with parents,
shall seek professional consultation from the RATIONALE: A school-age child develops a strong,
child's source of routine health care or a mental secure sense of identity through positive experiences
health professional.
with adults and peers (14, 15). An informal, enriching
RATIONALE: Three- and 4-year-old children continue environment that encourages self-paced cultivation of
to depend on the affection, physical care, intellectual interests and relationships promotes the self-worth of
guidance, and emotional support of their teachers school-age children.
(4, 13).
When children display behaviors that are unusual or
A supportive, nurturing setting that supports a dem- difficult to manage, caregivers should work with par-
onstration of feelings and accepts regression as part ents to seek a remedy that allows the child to suc-
of development continues to be vital for preschool ceed in the child care setting, if possible.
children. Preschool children need help building a posi-
tive self-image, a sense of self as a person of value COMMENTS: The first resource for addressing
from a family and a culture of which they are proud. behavior problems is the child’s source of routine
Children should be enabled to view themselves as health care. Support from a mental health profes-
coping, problem-solving, passionate, expressive sional may be needed. If the child’s health provider
individuals. cannot help or obtain help from a mental health pro-
fessional, the child care provider and the family may
COMMENTS: For additional qualifications and need a mental health consultant to advise about
responsibilities of teachers for centers and homes appropriate management of the child. Local mental
serving children between 3 and 5 years old, see also health agencies or pediatric departments of medical
General Qualifications for All Caregivers, schools may offer help from child psychiatrists, psy-
STANDARD 1.007 through STANDARD 1.011; and chologists, other mental health professionals skilled in
Training, STANDARD 1.023 through the issues of early childhood, and pediatricians who
STANDARD 1.036. have a subspecialty in developmental and behavioral
pediatrics.

Chapter 1: Staffing 10
Caring for Our Children:
National Health and Safety Performance Standards

For additional qualifications and responsibilities of a) A Bachelor’s degree in early childhood

teachers for centers serving school-age children, see education, child development, social work,
also General Qualifications for All Caregivers, nursing, or other child related field OR a
STANDARD 1.007through STANDARD 1.012; and combination of college coursework and
Training, STANDARD 1.023 through STANDARD experience, including:
1.036. 1) A minimum of four courses in child devel-
opment and early childhood education;
2) Two years of experience, under qualified
TYPE OF FACILITY: Center; Large Family Child Care supervision, working as a teacher serving
Home; Small Family Child Care Home the ages and developmental abilities of the
children enrolled in the center where the
individual will act as the director;
STANDARD 1.013 3) A course in business administration or
GENERAL QUALIFICATIONS FOR early childhood administration, or at least
ALL PERSONNEL OF CENTERS 6 months of on the job training in an
administrative position;
Staff members shall reflect the cultural, language, c) A valid certificate in pediatric first aid, includ-
and ethnic backgrounds of children enrolled in the ing management of a blocked airway, and res-
program. Centers shall have a plan of action for cue breathing, as specified in First Aid and
recruiting and hiring a diverse staff that is repre- CPR, STANDARD 1.026 through
sentative of the children in the facilities' care. STANDARD 1.028;
d) Knowledge of community resources available
RATIONALE: Young children's identities cannot be to children with special needs and the ability
separated from family, culture, and their home lan-
to use these resources to make referrals or
achieve interagency coordination;
guage. Children need to see successful role models e) Administrative and management skills in facil-
from their own ethnic and cultural groups and to ity operations;
develop the ability to relate to people who are differ- f) Capability in curriculum design;
ent from themselves. g) Oral and written communication skills;
h) Demonstrated life experience skills in working
COMMENTS: In staff recruiting, the hiring pool with children in more than one setting.
should extend beyond the immediate neighborhood
of the child's residence or location of the facility, to The director of a center enrolling more than 60
reflect the diversity of people with whom the child children shall have the above and at least 3 years
can be expected to have contact as a part of life experience as a teacher of children in the age
experience.
group(s) enrolled in the center where the individ-
ual will act as the director, plus at least 6 months
experience in administration.
TYPE OF FACILITY: Center
RATIONALE: The director of the facility is the team
leader of a small business. Both administrative and
QUALIFICATIONS OF DIRECTORS child development skills are essential for this individ-
OF CENTERS ual to manage the facility and set appropriate expecta-
tions. College-level coursework has been shown to
have a measurable, positive effect on quality child
STANDARD 1.014 care, whereas experience per se has not (3, 16, 17).
GENERAL QUALIFICATIONS OF
DIRECTORS The director of a center plays a pivotal role in ensur-
ing the day-to-day smooth functioning of the facility
The director of a center enrolling fewer than 60 within the framework of appropriate child develop-
children shall be at least 21 years old and shall have ment principles and knowledge of family relationships.
the following qualifications:

11 Chapter 1: Staffing
 Caring for Our Children:
National Health and Safety Performance Standards

The well-being of the children, the confidence of the because of the special requirements of the popula-
parents of children in the facility's care, and the high tions of children with special needs. The center is one
morale and consistent professional growth of the staff component in a network of services for children with
depend largely upon the knowledge, skills, and special needs in most communities. Every state partic-
dependable presence of a director who is able to ipating in Part C of IDEA is required to have a direc-
respond to long-range and immediate needs and able tory of services. Having a directory of services
to engage staff in decision-making that affects their available is useful and could fulfill part of the require-
day-to-day practice. Management skills are important ment. Many communities have agencies, such as local
and should be viewed primarily as a means of support resource and referral agencies, that gather informa-
for the key role of educational leadership that a direc- tion about services available to children with special
tor provides. A skilled director should know how to needs.
use community resources and to identify specialized
personnel to enrich the staff's understanding of For additional information on qualifications for direc-
behavior and curriculum content. Past experience tors of centers, see General Qualifications for All
working in an early childhood setting is essential to Caregivers, STANDARD 1.007 through STANDARD
running a facility. 1.013; and Training, STANDARD 1.023 through
STANDARD 1.036.
Life experience may include experience rearing one's
own children or previous personal experience TYPE OF FACILITY: Center
acquired in any child care setting. Work as a hospital
aide or at a camp for children with special needs
would qualify, as would experience in school settings. STANDARD 1.015
This experience, however, must be supplemented by MIXED DIRECTOR/TEACHER ROLE
competency-based training to determine and provide
whatever new skills are needed to care for children in Centers enrolling 30 or more children shall
child care settings. employ a non-teaching director. Centers with
fewer than 30 children may employ a director who
COMMENTS: The profession of early childhood edu- teaches as well.
cation is being informed by research on the associa-
tion of developmental outcomes with specific RATIONALE: The duties of a director of a facility
practices. The exact combination of college course- with more than 30 children do not allow the director
work and supervised experience is still being devel- to be involved in the classroom in a meaningful way.
oped. For example, the National Association for the
Education of Young Children (NAEYC) has published COMMENTS: This standard does not prohibit the
the Guidelines for Preparation of Early Childhood Profes- director from occasional substitute teaching, as long
sionals (18). Additional information on the early child- as the substitute teaching is not a regular and signifi-
hood education profession is available from cant duty. Occasional substitute teaching may keep
Wheelock College Institute for Leadership and the director in touch with the teachers’ issues.
Career Initiatives. The National Child Care Associa-
tion (NCCA) has developed a 40-hour curriculum TYPE OF FACILITY: Center
based on administrator competencies (19). Contact
information for the NAEYC, the Wheelock College
Institute for Leadership and Career Initiatives, and the
NCCA is located in Appendix BB.

The qualifications stipulated in the AAP/APHA stan-

dards, as well as state and local regulations for admin-
istrators of child care facilities that serve typically
developing children, may require supplementation

Chapter 1: Staffing 12
Caring for Our Children:
National Health and Safety Performance Standards

STANDARD 1.016 STANDARD 1.017

DIFFERENTIATED ROLES QUALIFICATIONS OF EDUCATION
COORDINATORS, LEAD TEACHERS,
Centers shall employ a teaching/caregiving staff for AND TEACHERS
direct work with children in a progression of roles,
as listed in descending order of responsibility: Education coordinators, lead teachers, and teach-
1 Education Coordinators; ers shall be at least 21 years of age and shall have
2 Lead Teachers; at least the following education, experience, and
3 Teachers; skills:
4 Associate Teachers; a) A Bachelor’s degree in early childhood educa-
5 Assistant Teachers; tion, child development, social work, nursing,
6 Aides. or other child-related field, or a combination
of experience and relevant college course-
Each role with increased responsibility shall work;
require increased educational qualifications and b) One year or more years of experience, under
experience, as well as increased salary. qualified supervision, working as a teacher
serving the ages and developmental abilities of
RATIONALE: A progression of roles enables centers the children in care;
to offer career ladders rather than dead-end jobs. It c) On-the-job training to provide a nurturing
promotes a mix of college-trained staff with other environment and to meet the child's out-of-
members of a child’s own community who might have home needs;
entered at the aide level and moved into higher roles d) A valid certificate in pediatric first aid,
through college or on-the-job training. including management of a blocked airway and
rescue breathing, as specified in First Aid and
Professional education and pre-professional inservice CPR, STANDARD 1.026 through
training programs provide an opportunity for career
STANDARD 1.028;
e) Knowledge of normal child development and
progression and can lead to job and pay upgrades and early childhood education, as well as
fewer turnovers. Turnover rates in child care posi- knowledge of children who are not developing
tions in 1997 averaged 30% (20). typically;
f) The ability to respond appropriately to child-
COMMENTS: Early childhood professional knowl- ren’s needs;
edge must be required whether programs are in pri- g) The ability to recognize signs of illness and
vate centers, public schools, or other settings. The safety hazards;
National Association for the Education of Young Chil- h) Oral and written communication skills.
dren’s (NAEYC) National Academy of Early Child-
hood Programs recommends a multi-level training Every center, regardless of setting, shall have at
program that addresses pre-employment educational
least one licensed/certified lead teacher (or men-
tor teacher) who meets the above requirements
requirements and continuing education requirements working in the child care facility at all times when
for entry-level assistants, teachers, and administra- children are in care.
tors. It also establishes a table of qualifications for
accredited programs (5). The NAEYC requirements Additionally, facilities serving children with special
include development of an employee compensation needs associated with developmental delay shall
plan to increase salaries and benefits to ensure have one licensed/certified teacher who is certified
recruitment and retention of qualified staff and conti- in special education.
nuity of relationships (18). The NAEYC’s recommen-
dations should be consulted in conjunction with the RATIONALE: Child care that promotes healthy deve-
standards in this document. lopment is based on the developmental needs of
infants, toddlers, and preschool children. Caregivers
TYPE OF FACILITY: Center are chosen for their knowledge of, and ability to
respond appropriately to, the needs of children of this

13 Chapter 1: Staffing
 Caring for Our Children:
National Health and Safety Performance Standards

age generally and the unique characteristics of individ- a) The ability to carry out assigned tasks compe-
ual children (2, 7, 12, 18). Both early childhood and tently under the supervision of another staff
special educational experience are useful in a center. member;
b) An understanding of and the ability to respond
COMMENTS: The profession of early childhood edu- appropriately to children’s needs;
cation is being informed by new research on child c) Sound judgement;
development practices related to child outcomes. For
d) Emotional maturity.
additional information on qualifications for child care
RATIONALE: While volunteers and students can be
staff, refer to the Guidelines for Preparation of Early
as young as 16, age 18 is the earliest age of legal con-
Childhood Professional from the National Association
sent. Mature leadership is clearly preferable. Age 21
for the Education of Young Children (NAEYC) (18).
allows for the maturity necessary to meet the respon-
Additional information on the early childhood educa-
sibilities of managing a center or independently caring
tion profession is available from Wheelock College
for a group of children who are not one's own.
Institute for Leadership and Career Initiatives and the
Center for the Child Care Workforce (CCW). Con-
Child care that promotes healthy development is
tact information is located in Appendix BB.
based on the developmental needs of infants, tod-
dlers, and preschool children. Caregivers are chosen
TYPE OF FACILITY: Center
for their knowledge of, and ability to respond appro-
priately to, the general needs of children of this age
and the unique characteristics of individual children
STANDARD 1.018 (2, 7, 12, 18).
QUALIFICATIONS FOR ASSOCIATE
TEACHERS, ASSISTANT TEACHERS, Staff training in child development and/or early child-
AIDES, AND VOLUNTEERS hood education is related to positive outcomes for
children (10). This training enables the staff to provide
Associate teachers shall be at least 18 years of age children with a variety of learning and social experi-
and shall have an Associate’s degree in early child-
hood education or child development, and 6 or ences appropriate to the age of the child. Everyone
more months’ of experience in child care. providing service to, or interacting with, children in a
center contributes to the child’s total experience.
Assistant teachers shall be at least 18 years of age,
have a high school diploma or GED, and partici- Adequate compensation for skilled workers will not
pate in on-the-job training, including a structured be given priority until the skills required are recog-
orientation to the developmental needs of young nized and valued. Caregiving requires skills to pro-
children and access to consultation, with periodic mote development and learning by children whose
review, by a supervisory staff member. needs and abilities change at a rapid rate.
Aides and volunteers shall be at least 16 years of COMMENTS: Experience and qualifications used by
age and shall participate in on-the-job training,
including a structured orientation to the develop- the Child Development Associate (CDA) program
mental needs of young children. Aides and volun- and the National Child Care Association credentialing
teers shall not be counted in the child:staff ratio program (NCCA) and included in degree programs
and shall work only under the continual supervi- with field placement are valued above didactic teach-
sion of qualified staff. ing alone. Early childhood professional knowledge
must be required whether programs are in private
Any driver who transports children for a child care centers, public schools, or other settings.
program shall be at least 21 years of age.
The National Association for the Education of Young
All associate teachers, assistant teachers, aides, Children's (NAEYC) National Academy of Early
drivers, and volunteers shall possess:

Chapter 1: Staffing 14
Caring for Our Children:
National Health and Safety Performance Standards

Childhood Programs has established a table of qualifi- d) Knowledge of normal child development, as
cations for accredited programs (5). well as knowledge of children who are not
developing typically;
Caregivers who lack educational qualifications may be e) The ability to respond appropriately to child-
employed as continuously supervised personnel while ren’s needs;
they acquire the necessary educational qualifications if f) Oral and written communication skills.
they have personal characteristics, experience, and
Additionally, large family child care home care -
skills in working with parents and children, and the givers shall have at least 1 year of experience,
potential for development on the job or in a training under qualified supervision, serving the ages and
program. developmental abilities of the children in their
large family child care home.
TYPE OF FACILITY: Center; Large Family Child Care
Home Assistants, aides, and volunteers employed by a
large family child care home shall meet the qualifi-
cations specified in STANDARD 1.018.
QUALIFICATIONS FOR CAREGIVERS RATIONALE: In both large and small family child care
OF LARGE AND SMALL FAMILY homes, staff members must have the education and
CHILD CARE HOMES experience to meet the needs of the children in care.
Small family child care home providers often work
alone and are solely responsible for the health and
STANDARD 1.019 safety of small numbers of children in care.
GENERAL QUALIFICATIONS OF
FAMILY CHILD CARE CAREGIVERS Age 18 is the earliest age of legal consent. Mature
leadership is clearly preferable. Age 21 is more likely
Caregivers in large and small family child care to be associated with the level of maturity necessary
homes shall be at least 21 years of age, hold an to independently care for a group of children who are
official credential as granted by the authorized not one's own.
state agency, meet the general requirements speci-
fied in STANDARD 1.007 through STANDARD The National Association for Family Child Care
1.012, based on ages of the children served, and
shall have the following education, experience, and (NAFCC) has established an accreditation process to
skills; enhance the level of quality and professionalism in
a) Current accreditation by the National Associ- small family child care (35). Contact information for
ation for Family Child Care (including entry- NAFCC is found in Appendix BB.
level qualifications and participation in
required training) and have a college certificate COMMENTS: A large family child care home provider
representing a minimum of 3 credit hours of caring for more than six children and employing one
family child care leadership or master care- or more assistants functions as a facility director. An
giver training or hold an Associate’s degree in operator of a large family-child-care home should be
early childhood education or child develop- offered training relevant to the management of a small
ment; child care center, including training on providing a
b) A valid certificate in pediatric first aid, includ-
ing management of a blocked airway and res- quality work environment for employees.
cue breathing, as specified in First Aid and
CPR, STANDARD 1.026 through STANDARD For more information on assessing the work environ-
1.028; ment of family child care employees, see Creating Bet-
c) Preservice training in health management in ter Family Child Care Jobs: Model Work Standards, a
child care, including the ability to recognize publication by the Center for the Child Care Work-
signs of illness and safety hazards; force (CCW) (21). Contact information for the CCW
is located in Appendix BB.

15 Chapter 1: Staffing
 Caring for Our Children:
National Health and Safety Performance Standards

TYPE OF FACILITY: Large Family Child Care Home; primary parent contact for health concerns,
Small Family Child Care Home including health-related parent/staff observations,
health-related information, and the provision of
resources. The health advocate shall also identify
STANDARD 1.020 children who have no regular source of health care
and refer them to a health care provider who
SUPPORT NETWORKS FOR FAMILY offers competent routine child health services.
CHILD CARE
For centers, the health advocate shall be licensed/
Large and small family child care home providers certified/credentialed as a director, lead teacher,
shall have active membership in local or state fam- teacher, or associate teacher, or shall be a health
ily child care associations (if such associations professional, health educator, or social worker
exist) or in the National Association for Family who works at the facility on a regular basis (at
Child Care (NAFCC), or belong to a network of least weekly).
family child care home providers that offers ongo-
ing training and information on how to provide The health advocate shall have documented train-
quality child care. ing in the following topics that include:
a) Sudden Infant Death Syndrome (SIDS), for
RATIONALE: Membership in peer professional orga- facilities caring for infants;
nizations shows a commitment to quality child care b) Control of infectious diseases, including Stan-
and also provides a conduit for information to other- dard/Universal Precautions;
wise isolated caregivers. Membership in a family child c) How to recognize and handle an emergency;
care association and attendance at meetings indicate d) Recognition and handling of seizures;
the desire to gain new knowledge about how to work e) Recognition of safety, hazards, and injury pre-
with children. vention interventions;
f) How to help parents, caregivers, and children
COMMENTS: For more information about family
cope with death, severe injury, and natural or
man-made catastrophes;
child care associations, contact the National Associa- g) Recognition of child abuse and neglect and
tion for Family Child Care (NAFCC). Contact infor- knowledge of when to contact a consultant;
mation is located in Appendix BB. h) Organization and implementation of a plan to
meet the emergency needs of children with
For additional qualifications and responsibilities of special health needs.
large and small family child care home providers, see
General Qualifications for All Caregivers, RATIONALE: The effectiveness of an intentionally
STANDARD 1.007 through STANDARD 1.012; and designated health advocate in improving the quality of
Training, STANDARD 1.023 through performance in a facility has been demonstrated in all
STANDARD 1.036. types of early childhood settings (22). A designated
caregiver with health training is effective in developing
TYPE OF FACILITY: Large Family Child Care Home; an ongoing relationship with the parents and a per-
Small Family Child Care Home sonal interest in the child (8, 23). Caregivers who are
better trained are more able to prevent, recognize,
and correct health and safety problems. An internal
STANDARD 1.021 advocate for issues related to health and safety can
QUALIFICATIONS FOR HEALTH help integrate these concerns with other factors
ADVOCATES involved in formulating facility plans.

Each facility shall designate a person as health COMMENTS: The director should assign the health
advocate to be responsible for policies and day-to- advocate role to a staff member who seems to have
day issues related to health, development, and an interest, aptitude and training in this area. This per-
safety of individual children, children as a group, son need not perform all the health and safety tasks in
staff, and parents. The health advocate shall be the

Chapter 1: Staffing 16
Caring for Our Children:
National Health and Safety Performance Standards

the facility but should serve as the person who raises child's immunization records at least quarterly and
health and safety concerns. This staff person has des- for identifying and referring, to their usual source
ignated responsibility for seeing that plans are imple- of health care, children in need of additional
mented to ensure a safe and healthful facility (22). immunizations.

A health advocate is a regular member of the staff of a RATIONALE: Children require frequent immuniza-
center or large or small family child care home net- tions in early childhood. Although children may be
work, and is not the same as the health consultant current with required immunizations when they
recommended in Health Consultants, STANDARD enroll, they sometimes miss scheduled immunizations
1.040 through STANDARD 1.044. For small family thereafter. Because the risk of vaccine-preventable
child care homes, the health advocate will usually be disease increases in group settings, assuring appropri-
the caregiver. If the health advocate is not the child’s ate immunizations is an essential responsibility in child
caregiver, the health advocate should work with the care.
child's caregiver. The person who is most familiar with
the child and the child’s family will recognize atypical COMMENTS: For more information on immuniza-
behavior in the child and support effective communi- tions, see STANDARD 3.005 and STANDARD 3.006.
cation with parents.
TYPE OF FACILITY: Center; Large Family Child Care
A plan for personal contact with parents should be Home; Small Family Child Care Home
developed, even though this contact will not be possi-
ble daily. A plan for personal contact and documenta-
tion of a designated caregiver as health advocate will 1.4 TRAINING
ensure specific attempts to have the health advocate
communicate directly with caregivers and families on ORIENTATION TRAINING
health-related matters.

For additional qualifications and responsibilities of STANDARD 1.023

health advocates, see Training, STANDARD 1.023 INITIAL ORIENTATION OF ALL
through STANDARD 1.036; and Direct Care and STAFF
Provisional Staff, STANDARD 1.009 through
STANDARD 1.013. All new full-time and part-time staff shall be ori-
ented to, and demonstrate knowledge of, the
TYPE OF FACILITY: Center; Large Family Child Care items listed below. The director of any center or
Home; Small Family Child Care Home large family child care home shall provide this
training to all newly hired caregivers before they
begin to care for children. For centers, the direc-
tor shall document, for each new staff member,
STANDARD 1.022 the topics covered and the dates of orientation
STAFF WHO CHECK training. Staff members shall not be expected to
IMMUNIZATION RECORDS take responsibility for any aspect of care for which
their orientation and training have not prepared
At least one caregiver shall have knowledge of them.
childhood immunization requirements and shall be
responsible for periodically reviewing the Small family child care home providers shall avail
children’s immunization records to ensure that themselves of orientation training offered by the
they are current. The caregiver shall have sufficient licensing agency, a resource and referral agency, or
knowledge of childhood immunization other such agency. This training shall include evalu-
requirements to be able to review immunization ation that involves demonstration of the knowl-
records and determine which immunizations are edge and skills covered in the training lesson.
needed and when they should be given. This
person shall be responsible for reviewing each

17 Chapter 1: Staffing
 Caring for Our Children:
National Health and Safety Performance Standards

The orientation shall address, at a minimum: 2) Diapering technique and toilet use, if care
a) Regulatory requirements; is provided to children in diapers and/or
b) The goals and philosophy of the facility; children needing help with toilet use,
c) The names and ages of the children for whom including appropriate diaper disposal and
the caregiver will be responsible, and their diaper-changing techniques. See Toilet,
specific developmental needs; Diapering, and Bath Areas, STANDARD
d) Any special adaptation(s) of the facility 5.116 through STANDARD 5.125; Toilet
required for a child with special needs for Use, Diapering, and Toilet Learning/
whom the staff member might be responsible Training, STANDARD 3.012 through
at any time; STANDARD 3.019; Toilet Learning/
e) Any special health or nutrition need(s) of the Training Equipment, Toilets, and
children assigned to the caregiver; Bathrooms, STANDARD 3.029 through
f) The planned program of activities at the facil- STANDARD 3.033;
ity. See Program of Developmental Activities, 3) Identifying hazards and injury prevention;
STANDARD 2.001 through 4) Correct food preparation, serving, and
STANDARD 2.027; storage techniques if employee prepares
g) Routines and transitions; food. See Food Safety, STANDARD 4.042
h) Acceptable methods of discipline. See through STANDARD 4.060;
Discipline, STANDARD 2.039 through 5) Knowledge of when to exclude children
STANDARD 2.043; and Discipline Policy, due to illness and the means of illness
STANDARD 8.008 through transmission;
STANDARD 8.010; 6) Formula preparation, if formula is handled.
i) Policies and practices of the facility about See Plans and Policies for Food Handling,
relating to parents. See Parent Relationships, Feeding, and Nutrition, STANDARD 8.035
STANDARD 2.044 through and STANDARD 8.036; and Nutrition for
STANDARD 2.057; Infants, STANDARD 4.011 through
j) Meal patterns and food handling policies and STANDARD 4.021;
practices of the facility. See Plans and Policies 7) Standard precautions and other measures
for Food Handling, Feeding, and Nutrition, to prevent exposure to blood and other
STANDARD 8.035 and STANDARD 8.036; body fluids, as well as program policies and
Food Service Records, STANDARD 8.074; procedures in the event of exposure to
Nutrition and Food Service, STANDARD blood/body fluid. See Prevention of Expo-
4.001 through STANDARD 4.070; sure to Body Fluids, STANDARD 3.026;
k) Occupational health hazards for caregivers, n) Recognizing symptoms of illness. See Daily
including attention to the physical health and Health Assessment, STANDARD 3.001 and
emotional demands of the job and special con- STANDARD 3.002;
siderations for pregnant caregivers. See Occu- o) Teaching health promotion concepts to
pational Hazards, STANDARD 1.048; and children and parents as part of the daily care
Major Occupational Health Hazards, provided to children. See Health Education for
Appendix B; Children, STANDARD 2.060 through
l) Emergency health and safety procedures. See STANDARD 2.063;
Plan for Urgent Medical Care or Threatening p) Child abuse detection, prevention, and
Incidents, STANDARD 8.022 and reporting. See Child Abuse and Neglect,
STANDARD 8.023; and Emergency STANDARD 3.053 through
Procedures, STANDARD 3.048 through STANDARD 3.059;
STANDARD 3.052; q) Medication administration policies and
m) General health and safety policies and practices;
procedures, including but not limited to the r) Putting infants down to sleep positioned on
following: their backs and on a firm surface to reduce
1) Handwashing techniques and indications the risk of Sudden Infant Death Syndrome
for handwashing. See Handwashing, (SIDS).
STANDARD 3.020 through STANDARD
3.024;

Chapter 1: Staffing 18
Exploring the Variety of Random
Documents with Different Content
The text on this page is estimated to be only 27.31%
accurate

LITERATURE OF THE EAST 161 in the Sektet boat, and may

he cleave his path among the never-resting stars in the heavens."
Osiris Ani, being in peace and in triumph, adoreth his lord, the lord
of eternity, saying : " Homage to thee, O Herukhuti (Harmakhis),
who art the god Khepera, the selfcreated; when thou risest on the
horizon and sheddest thy beams of light upon the lands of the North
and of the South, thou art beautiful, yea beautiful, and all the gods
rejoice when they behold thee, the King of heaven. The goddess
Nebtrnnut is stablished upon thy head ; and her ursei of the South
and of the North are upon thy brow ; she taketh up her place before
thee. The god Thoth is stablished in the bows of thy boat to destroy
utterly all thy foes. Those who are in the Tuat (underworld) come
forth to meet thee, and they bow in homage as they come toward
thee, to behold thy beautiful Image. And I have come before thee
that I may be with thee to behold thy Disk every day. May I not be
shut up in the tomb, may I not be turned back, may the limbs of my
body be made new again when I view thy beauties, even as are
those of all thy favored ones, because I am one of those who
worshiped thee whilst I lived upon earth. May I come in unto the
land of eternity, may I come even unto the everlasting land, for
behold, O my lord, this hast thou ordained for me." And lo, Osiris
Ani, triumphant in peace, the triumphant one, saith : " Homage to
thee, O thou who risest in thy horizon as Re, thou reposest upon law
which changeth not nor can be altered. Thou passest over the sky,
and every face watcheth thee and thy course, for thou hast been
hidden from their gaze. Thou dost show thyself at dawn and at
eventide day by day. The Sektet boat, wherein is thy Majesty, goeth
forth with might ; thy beams shine upon all faces ; the number of
thy red and yellow rays can not be known, nor can thy briirht beams
be told. The lands of the gods, and the eastern lands of Punt 7 must
be seen, ere that which is hidden in thee may be measured. Alone
and by thyself thou dost manifest thyself when thou comest into
being above Nu (i.e., the sky). May Ani advance, even as thou dost
advance; may he never 7 I.e., the land on each side of the Red Sea
and on the coast of Africa. VOL. II.— 11.
The text on this page is estimated to be only 28.08%
accurate

162 THE SACRED BOOKS cease to go forward, even as thy

Majesty ceaseth not to go forward, even though it be for a moment;
for with strides dost thou in one little moment pass over the spaces
which would need hundreds of thousands and millions of years for
man to pass over; this thou doest, and then dost thou sink to rest.
Thou puttest an end to the hours of the night, and thou dost count
them, even thou; thou endest them in thine own appointed season,
and the earth becometh light. Thou settest thyself before thy
handiwork in the likeness of Re, thou risest in the horizon." Osiris,
the scribe Ani, triumphant, declareth his praise of thee when thou
shinest, and when thou risest at dawn he crieth in his joy at thy birth
: " Thou art crowned with the majesty of thy beauties; thou moldest
thy limbs as thou dost advance, and thou bringest them forth
without birth-pangs in the form of Re, as thou dost rise up into the
upper air. Grant thou that I may come unto the heaven which is
everlasting, and unto the mountain where dwell thy favored ones.
May I be joined unto those shining beings, holy and perfect, w4io
are in the underworld ; and may I come forth with them to behold
thy beauties when thou shinest at eventide and goest to thy mother
Nu. Thou dost place thyself in the west, and my two hands are
raised in adoration of thee when thou settest as a living being.
Behold, thou art the maker of eternity, and thou art adored when
thou settest in the heavens. I have given my heart unto thee without
wavering, O thou who art mightier than the gods." Osiris Ani,
triumphant, saith : " A hymn of praise to thee, O thou who risest like
unto gold, and who dost flood the world with light on the day of thy
birth. Thy mother giveth thee birth upon her hand, and thou dost
give light unto the course of the Disk. O thou great Light, who
shinest in the heavens, thou dost strengthen the generations of men
with the Nile-flood, and thou dost cause gladness in all lands, and in
all cities, and in all the temples. Thou art glorious by reason of thy
splendors, and thou makest strong thy Jca (i.e., Double) with hu and
tchefau foods. O thou who art the mighty one of victories, thou who
art the Power of all powers, who dost
The text on this page is estimated to be only 27.18%
accurate

LITERATURE OF THE EAST 163 make strong thy throne

against evil fiends ; who art glorious in majesty in the Sektet boat,
and who art exceeding mighty in the Atet boat, make thou glorious
Osiris Ani with victory in the underworld ; grant thou that in the
netherworld he may be without evil. I pray thee to put away his
faults behind thee: grant thou that he may be one of thy venerable
servants who are with the shining ones; may he be joined unto the
souls which are in Ta-tchesertet ; and may he journey into the
Sekhet-Aaru by a prosperous and happy decree, he the Osiris, the
scribe, Ani, triumphant." And the god saith : " Thou shalt come forth
into heaven, thou shalt pass over the sky, thou shalt be joined into
the starry deities. Praises shall be offered unto thee in thy boat, thou
shalt be hymned in the Atet boat, thou shalt behold Re within his
shrine, thou shalt set together with his Disk day by day, thou shalt
see the Ant fish when it springeth into being in the waters of
turquoise, and thou shalt see the Abtu fish in his hour. It shall come
to pass that the Evil One shall fall when he layeth a snare to destroy
thee, and the joints of his neck and of his back shall be hacked
asunder. Re saileth with a fair wind, and the Seklet boat draweth on
and cometh into port. The mariners of Re rejoice, and the heart of
Nebt-ankh 8 is glad, for the enemy of her lord hath fallen to the
ground. Thou shalt behold Horus on the standing-place of the pilot
of the boat, and Thoth and Maat shall stand one upon each side of
him. All the gods shall rejoice when they behold Re coming in peace
to make the hearts of the shining ones to live, and Osiris Ani,
victorious, the scribe of the divine offerings of the lords of Thebes,
shall be along with them ! " HYMN TO THE SETTING SUN9
ANOTHER CHAPTER OF THE MYSTERY OF THE TUAT
(UNDERWORLD) AND OF PASSING THROUGH THE UNSEEN
NETHERWORLD, and of seeing the Disk when he setteth in • I.e. "
Lady of life," a name of lais. • From the Papyrus of Mut-hetep.
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164. THE SACRED BOOKS Amentet, when he is adored by

the gods and by the Khus in the underworld, and when the Soul
which dwelleth in Re is made perfect. He is made mighty before
Tern; he is made great before Osiris ; he setteth his terror before the
company of the gods who are the guides of the netherworld ; he
maketh long his steps and he maketh his face to enter with that of
the great god. Now every Khu, for whom these words shall have
been said, shall come forth by day in any form which he is pleased
to take ; he shall gain power among the gods of the Tuat
(underworld), and they shall recognize him as one of themselves;
and he shall enter in at the hidden gate with power. The lady Mut-
hetep, victorious, singeth hymns of praise to thee saying : " O Re-
Tern, in thy splendid progress thou risest, and thou settest as a
living being in the glories of the western horizon; thou settest in thy
territory which is in Manu. Thy uraeus is behind thee, thy urseus is
behind thee. Homage to thee, O thou who art in peace, homage to
thee, O thou who art in peace. Thou art joined unto the Eye of Tern,
and it chooseth its powers of protection to place behind thy
members. Thou goest forth through heaven, thou travelest over the
earth, and thou journeyest onward. O Luminary, the northern and
southern halves of heaven come to thee and they bow low in
adoration, and they pay homage unto thee, day by day. The gods of
Amentet rejoice in thy beauties and the unseen places sing hymns of
praise unto thee. Those who dwell in the Sekiet boat go round about
thee, and the Souls of the East pay homage to thee, and when they
meet thy Majesty they cry : ' Come, come in peace ! ' There is a
shout of welcome to thee, O lord of heaven and governor of
Amentet ! Thou art acknowledged by Isis who seeth her son in thee,
the lord of fear, the mighty one of terror. Thou settest as a living
being in the hidden place. Thy father Tatunen raiseth thee up, and
he placeth both his hands behind thee; thou becomest endowed
with divine attributes in thy members of earth ; thou wakest in
peace and thou settest in Manu. Grant thou that I may become a
being honored before Osiris, and that I may come to thee, O Re-Tern
!I
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LITERATURE OF THE EAST 165 have adored thee, therefore

do thou for me that which I wish. Grant thou that I may be
victorious in the presence of the company of the gods. Thou art
beautiful, O Re, in thy western horizon of Amentet, thou lord of
Maat, thou mighty one of fear, thou whose attributes are majestic, O
thou who art greatly beloved by those who dwell in the Tuat
(underworld) ; thou shinest with thy beams upon the beings that are
therein perpetually, and thou sendest forth thy light upon the path of
Re-stau. Thou openest up the path of the double Lion-god, thou
settest the gods upon their thrones, and the Khus in their abiding-
places. The heart of Naarerf is glad when Re setteth, the heart of
Naarerf is glad when Re setteth. " Hail, O ye gods of the land of
Amentet who make offerings and oblations unto Re-Tern, ascribe ye
glory unto him when ye meet him. Grasp ye your weapons and
overthrow ye the fiend Seba on behalf of Re, and repulse the fiend
Nebt on behalf of Osiris. The gods of the land of Amentet rejoice
and lay hold upon the cords of the Sektet boat, and they come in
peace ; the gods of the hidden place who dwell in Amentet triumph.
" Hail, Thoth, who didst make Osiris to triumph over his enemies,
make thou Mut-hetep victorious, to triumph over her enemies in the
presence of the great divine sovereign chiefs who live with Osiris,
the lord of life. The great god who dwelleth in his Disk cometh forth,
that is, Horus the avenger of his father Unnefer-Re. Osiris setteth,
and the Klius who are in the Tuat (underworld) say: Homage to
thee, O thou who comest as Tern, and who comest into being as the
creator of the gods. Homage to thee, O thou who comest as the
holy Soul of souls, who dwellest in the horizon. Homage to thee who
art more glorious than all the gods and who illuminest the Tuat with
thine Eye. Homage to thee who sailest in thy glory and who goest
round about it in thy Disk." [The following variant of the above hymn
is translated from the text in the Papyrus of Nekhtu-Amen (Naville, "
Todtenbuch" r>
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166 THE SACRED BOOKS UNDER WORLD, of seeing the

Disk when he setteth in Amentet, when he is adored by the gods
and by the Khus of the Tuat (underworld), and when the divine Khu
which dwelleth within Re is made perfect. He setteth his might
before Re, he setteth his power before Tern, he setteth his strength
before Khenti-Amentet, and he setteth his terror before the company
of the gods. The Osiris of the gods goeth as leader through the Tuat
(underworld), he crasheth through mountains, he bursteth through
rocks, he maketh glad the heart of every Khu. This composition shall
be recited by the deceased when he cometh forth and when he
goeth in with the gods, among whom he findeth no opposition; then
shall he come forth by day in all the manifold and exceedingly
numerous forms which he may be pleased to take. The Osiris . . .
saith: " A hymn of praise to Re at eventide when he setteth as a
living being in Baakha.10 The great god who dwelleth in his Disk
riseth in his two eyes n and all the Khus of the underworld receive
him in his horizon of Amentet; they shout praises unto Heru-khuti
(Harmakhis) in his form of Tern, and they sing hymns of joy to Re
when they have received him at the head of his beautiful path of
Amentet." He (i.e., the deceased) saith: " Praise be unto thee, O Re,
praise be unto thee, O Tern, in thy splendid progress. Thou hast
risen and thou hast put on strength, and thou settest like a living
being amid thy glories in the horizon of Amentet, in thy domain
which is in Manu. Thy uraus-goddess is behind thee; thy uraeus-
goddess is behind thee. Hail to thee, in peace ; hail to thee, in
peace. Thou joinest thyself unto the Eye of Horus, and thou hidest
thyself within its secret place ; it destroyeth for thee all the
convulsions of thy face, it maketh thee strong with life, and thou
livest. It bindeth its protecting amulets behind thy members. Thou
sailest forth over heaven, and thou maketh the earth to be
stablished ; thou joinest thyself unto the upper heaven, O Luminary.
The two re*o I.e., the mountain of sunrise, but the scribe appears to
have written * Baakha" instead of "Manu." "The Sun and the Moon.
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LITERATURE OF THE EAST 167 gions of the East and West

make adoration unto thee, bowing low and paying homage unto
thee, and they praise thee day by day; the gods of Amentet rejoice
in thy splendid beauties. The hidden places adore thee, the aged
ones make offerings unto thee, and they create for thee protecting
powers. The divine beings who dwell in the eastern and western
horizons transport thee, and those who are in the Sektet boat
convey thee round and about. The Souls of Ainentet cry out unto
thee and say unto thee when they meet thy Majesty (life, health,
strength!), 'All hail, all hail!' When thou comest forth in peace there
arise shouts of delight to thee, O thou lord of heaven, thou Prince of
Amentet. Thy mother Isis embraceth thee, and in thee she
recognizeth her son, the lord of fear, the mighty one of terror. Thou
settest as a living being within the dark portal. Thy father Tatunen
lifteth thee up and he stretcheth out his two hands behind thee ;
thou becomest a divine being in the earth. Thou wakest as thou
settest, and thy habitation is in Manu. Grant thou that I may be
venerated before Osiris, and come thou to me, O ReTern. Since thou
hast been adored by me, that which I wish thou shalt do for me day
by day. Grant thou victory unto me before the great company of the
gods, O Re who art doubly beautiful in thy horizon of Amentet, thou
lord of Maat who dwellest in the horizon. The fear of thee is great,
thy forms are majestic, and the love of thee is great among those
who dwell in the underworld." HYMN TO THE SETTING SUN 12 A
HYMN OF PRAISE TO RE-HERU-KHUTI (RE-HARMAKHIS) WHEN HE
SETTETH IN THE WESTERN PART OF HEAVEN. He (i.e., the
deceased) saith: " Homage to thee, O Re who in thy sitting art Tem-
Herukhuti (Tem-Harmakhis), thou divine god, thou self-crentc'l
being, thou primeval matter from which all things were made. When
thou appearest in the bows of thy bark men « From a Papyrus of the
Nineteenth Dynasty preserved at Dublin.
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168 THE SACRED BOOKS shout for joy at thee, O maker of

the gods! Thou didst stretch out the heavens wherein thy two eyes
might travel, thou didst make the earth to be a vast chamber for thy
Khus, so that every man might know his fellow. The SeJctet boat is
glad, and the Matet boat rejoiceth; and they greet thee with
exaltation as thou journeyest along. The god Nu is content, and thy
mariners are satisfied ; the uraus-goddess hath overthrown thine
enemies, and thou hast carried off the legs of Apep. Thou art
beautiful, O Re, each day, and thy mother Nut embraceth thee; thou
settest in beauty, and thy heart is glad in the horizon of Manu, and
the holy beings therein rejoice. Thou shinest there with thy beams,
O thou great god, Osiris, the everlasting Prince. The lords of the
zones of the Tuat in their caverns stretch out their hands in
adoration before thy Ka (double), and they cry out to thee, and they
all come forth in the train of thy form shining brilliantly. The hearts
of the lords of the Tuat (underworld) are glad when thou sendest
forth thy glorious light in Amentet; their two eyes are directed
toward thee, and they press forward to see thee, and their hearts
rejoice when they do see thee. Thou harkenest unto the
acclamations of those that are in the funeral chest,13 thou doest
away with their helplessness and drivest away the evils which are
about them. Thou givest breath to their nostrils and they take hold
of the bows of thy bark in the horizon of Manu. Thou art beautiful
each day, O Re, and may thy mother Nut embrace Osiris . . . ,14
victorious." THE CHAPTER OF THE CHAPLET OF VICTORY THE
CHAPTER OF THE CHAPLET OF VICTORY. Osiris Aufankh, victorious,
born of Sheret-Amsu, victorious, saith : " Thy father Tern hath
woven for thee a beautiful chaplet of vvictory to be placed on thy
living brow, O thou who lovest the gods, and thou shalt live forever.
Osiris-khent-Amentet 15 is I.e.t the dead. i* The name of the
deceased is wanting. "/.e., Osiris, governor of Amentet.
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LITERATURE OF THE EAST 169 hath made thee to triumph

over thine enemies, and thy father Seb hath decreed for thee all his
inheritance. Come, therefore, O Horus, son of Isis, for thou, O son of
Osiris, sittest upon the throne of thy father Re to overthrow thine
enemies, for he hath ordained for thee the two lands to their utmost
limits. Atem hath also ordained this, and the company of the gods
hath confirmed the splendid power of the victory of Horus the son of
Isis and the son of Osiris forever and forever. And Osiris Auf-ankh
shall be victorious forever and ever. O Osiris-khent-Amentet, the
whole of the northern and southern parts of the heavens, and every
god and every goddess, who are in heaven and who are upon earth,
will the victory of Horus, the son of Isis and the son of Osiris, over
his enemies in the presence of Osiris-khentAmentet who will make
Osiris Auf-ankh, victorious, to triumph over his enemies in the
presence of Osiris-khent-Amentet, Un-nefer, the son of Nut, on the
day of making him to triumph over Set and his fiends in the
presence of the great sovereign chiefs who are in Annu (Heliopolis) ;
on the night of the battle and overthrow of the Seba-fiend in the
presence of the great sovereign princes who are in Abtu ; on the
night of making Osiris to triumph over his enemies make thou Osiris
Auf-ankh, triumphant, to triumph over his enemies in the presence
of the great sovereign princes, who are in the horizon of Amentet ;
on the day of the festival of Haker in the presence of the great
sovereign princes who are in Tattu ; on the night of the setting up of
the Tet in Tattu in the presence of the great sovereign princes who
are in the ways of the damned ; on the night of the judgment of
those who shall be annihilated in the presence of the great sovereign
princes who are in Sekhem (Letopolis) ; on the night of the * things
of the altars in Sekhem ' in the presence of the great sovereign
princes who are in Pe and Tepu ; on the night of the stablishing of
the inheriting by Horus of the things of his father Osiris in the
presence of the great sovereign princes who are at the great festival
of the plowing and turning up of the earth in Tattu," or (as others
say), "in Abtu; on the night of the weighing of
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170 THE SACRED BOOKS words," or (as others say),

"weighing of locks in the presence of the great sovereign princes
who are in An-rut-f on its place; on the night when Horus receiveth
the birthchamber of the gods in the presence of the great sovereign
princes who are in the lands of Rekhti; on the night when Isis lieth
down to watch and to make lamentation for her brother in the
presence of the great sovereign princes who are in Re-stau; on the
night of making Osiris to triumph over all his enemies. " Horus
repeated these words four times, and all his enemies fell headlong
and were overthrown and were cut to pieces; and Osiris Auf-ankh,
triumphant, repeated these words four times, therefore let all his
enemies fall headlong, and be overthrown and cut to pieces. Horus,
the son of Isis and son of Osiris, celebrated in turn millions of
festivals, and all his enemies fell headlong, and were overthrown and
cut to pieces. Their habitation hath gone forth to the block of the
East, their heads have been cut off ; their necks have been
destroyed; their thighs have been cut off; they have been given over
to the Great Destroyer who dwellcst in the valley of the grave ; and
they shall never come forth from under the restraint of the god Seb."
THIS CHAPTER SHALL BE RECITED OVER THE DIVINE CHAPLET
WHICH IS LAID UPON THE FACE OF THE DECEASED, AND THOU
SHALT CAST INCENSE INTO THE FIRE ON BEHALF OF OSIRIS AUF-
ANKH, TRIUMPHANT, BORN OF SHERET-AMSU, TRIUMPHANT ;
THUS SHALT THOU CAUSE HIM TO TRIUMPH OVER HIS ENEMIES,
DEAD OR ALIVE, AND HE SHALL BE AMONG THE FOLLOWERS OF
OSIRIS ; AND A HAND SHALL BE STRETCHED OUT TO HIM WITH
MEAT AND DRINK IN THE PRESENCE OF THE GOD. THIS CHAPTER
SHALL BE SAID BY THEE TWICE AT DAWN NOW IT IS A NEVER-
FAILING CHARM REGULARLY AND CONTINUALLY.
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LITERATURE OF THE EAST 171 THE CHAPTER OF THE

VICTORY OVER ENEMIES 16 " Hail, Thoth, who didst make Osiris to
triumph over his enemies, snare thou the enemies of Osiris, the
scribe Nebseni, the lord of piety, in the presence of the great
sovereign princes of every god and of every goddess; in the
presence of the great sovereign princes who are in Annu (Heliopolis)
on the night of the battle and of the overthrow of the Sebaufiend in
Tattu ; on the night of making to stand up the double Tet in Sekliem
(Letopolis) ; on the night of the things of the night in Sekhem, in Pe,
and in Tepu ;17 on the night of the stablishing of Horus in the
heritage of the things of his father in the double land of Rekhti ; on
the night when Isis maketh lamentation at the side of her brother
Osiris in Abtu (Abydos) ; on the night of the Haker festival of the
distinguishing between the dead (i.e., the damned) and the KJius on
the path of the dead (i.e.t the damned) ; on the night of the
judgment of those who are to be annihilated at the great festival of
the plowing and the turning up of the earth in Naare-rut-f in Re-
stau; and on the night of making Horus to triumph over his enemies.
Horus is mighty, the northern and southern halves of heaven rejoice,
Osiris is content thereat and his heart is glad. Hail, Thoth, make
thou to triumph Osiris, the scribe Nebseni, over his enemies in the
presence of the sovereign princes of every god and every goddess,
and in the presence of you, ye sovereign princes who passed
judgment on Osiris behind the shrine." [In the Sai'te Recension this
chapter has no vignette, but it has the title " Another Chapter of the
Chaplet of Victory," and is arranged in tabular form. The words, "
Hail, Thoth, make Osiris Auf-ankh, triumphant, to triumph over his
enemies even as thou didst make Osiris to triumph over his
enemies," which are written in two horizontal lines, are to be
repeated before each column of text. The " great sovereign »• From
the Papyrus of Nebseni. " Pe and Tepu were two famous sanctuaries
of northern Egypt.
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172 THE SACRED BOOKS princes" invoked are those of: (1)
Annu (Heliopolis), (2) Tattu, (3) Sekhem (Letopolis), (4) Pe and
Tepu, (5) Anarut-f, (6) the double land of Rekhti, (7) Re-stau, (8)
Abtu, (9) the paths of the dead, (10) the plowing festival in Tattu,
(11) Kher-aba, (12) Osiris, (13) heaven and earth, (14) every god
and every goddess. The rubric reads :] IF THIS CHAPTER BE
RECITED REGULARLY AND ALWAYS BY A MAN WHO IIATII
PURIFIED HIMSELF IN WATER OF NATRON, HE SHALL COME FORTH
BY DAY AFTER HE HATH COME INTO PORT (i.e., is DEAD), AND HE
SHALL PERFORM ALL THE TRANSFORMATIONS WHICH HIS HEART
SHALL DICTATE, AND HE SHALL COME FORTH FROM EVERY FIRE.
THE CHAPTER OF GIVING A MOUTH TO THE OVERSEER THE
CHAPTER OF GIVING A MOUTH TO THE OVERSEER OF THE HOUSE,
Nu, TRIUMPHANT, IN THE UNDERWORLD. He saith : " Homage to
thee, O thou lord of brightness, thou who art at the head of the
Great House, prince of the night and of thick darkness. I have come
unto thee being a pure khu. Thy two hands are behind thee, and
thou hast thy lot with thy ancestors. Oh, grant thou unto me my
mouth that I may speak therewith ; and guide thou to me my heart
at the season when there is cloud — and darkness." THE CHAPTER
OF GIVING A MOUTH TO OSIRIS ANI 18 THE CHAPTER OF GIVING
A MOUTH TO OSIRIS ANI, THE SCRIBE AND TELLER OF THE HOLY
OFFERINGS OF ALL THE GODS, TRIUMPHANT, IN THE
UNDERWORLD. He Saith I " I rise out of the egg in the hidden land.
May my mouth be given unto me that I may speak therewith in the
presence of the great god, the lord of the Tuat (underworld). May is
From the Papyrus of Ani.
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LITERATURE OF THE EAST 173 my hand and my arm not

be forced back in the presence of the sovereign princes of any god. I
am Osiris, the lord of Restau ; may I, Osiris the scribe Ani,
triumphant, have a portion with him who is on the top of the steps
(i.e., Osiris). According to the desire of my heart, I have come from
the Pool of Fire, and I have quenched the fire." OPENING THE
MOUTH OF OSIRIS THE CHAPTER OF OPENING THE MOUTH OF
OSIRIS. The scribe Ani, triumphant, saith : " May the good Ptah
open my mouth, and may the god of my city loose the swathings,
even the swathings which are over my mouth. Moreover, may Thoth,
being filled and furnished with charms, come and loose the
bandages, even the bandages of Set which fetter my mouth ; and
may the god Tern hurl them at those who would fetter me with
them, and drive them back. May my mouth be opened, may my
mouth be unclosed by Shu with his iron knife wherewith he opened
the mouths of the gods. I am the goddess Sekhet, and I sit upon my
place in the great wind of heaven. I am the great goddess Sah who
dwelleth among the Souls of Annu (Heliopolis). Now as concerning
every charm and all the words which may be spoken against me,
may the gods resist them, and may each and every one of the
company of the gods withstand them." THE CHAPTER OF BRINGING
CHARMS TO OSIRIS THE CHAPTER OF BRINGING CHARMS UNTO
OSIRIS ANI IN THE UNDERWORLD. He saith : " I am Tem-Khepera,
who brought himself into being upon the thigh of his divine mother.
Those who are in Nu (i.e., the sky) are made wolves, and those who
are among the sovereign princes are become hyenas. Behold, I
gather together the charm from every place where it is, and from
every man with whom it is, swifter than greyhounds and
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174 THE SACRED BOOKS quicker than light. Hail, thou who
towest along the Malehent boat of Re, the stays of thy sails and of
thy rudder are taut in the wind as thou sailest up the Pool of Fire in
the underworld. Behold, thou gatherest together the charm from
every place where it is, and from every man with whom it is, swifter
than greyhounds and quicker than light, the charm which created
the forms of being from the . . . mother, and which either createth
the gods or maketh them silent, and which giveth the heat of fire
unto the gods. Behold, the charm is given unto me, from wherever it
is and from him with whom it is, swifter than greyhounds and
quicker than light," or (as others say) " quicker than a shadow." THE
CHAPTER OF MEMORY 19 THE CHAPTER OF MAKING A MAN TO
POSSESS MEMORY IN THE UNDERWORLD. The chancellor-in-chief,
Nu, triumphant, the overseer of the palace, the son of the chief
chancellor Amen-hetep, saith: " May my name be given to me in the
Great House, and may I remember my name in the House of Fire on
the night of counting the years and of telling the number of the
months, I am with the Divine One, and I sit on the eastern side of
heaven. If any god whatsoever should advance unto me, let me be
able to proclaim his name forthwith." THE CHAPTER OF GIVING A
HEART TO OSIRIS *> THE CHAPTER OF GIVING A HEART TO
OSIRIS ANI IN THE UNDERWORLD. He saith : " May my heart (ab)
21 be with me in the House of Hearts! May my heart (hat) be with
me in the House of Hearts ! May my heart be with me, and may it
rest there, i» From the Papyrus of Nu. 20 From the Papyrus of Ani.
21 Ab is undoubtedly the "heart," and hat is the region wherein is
the heart ; the word may be fairly well rendered by " breast," though
the pericardium is probably intended.
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LITERATURE OF THE EAST 175 or I shall not eat of the

cakes of Osiris on the eastern side of the Lake of Flowers, neither
shall I have a boat wherein to go down the Nile, nor another
wherein to go up, nor shall I be able to sail down the Nile with thee.
May my mouth be given to me that I may speak therewith, and my
two legs to walk therewith, and my two hands and arms to
overthrow my foe. May the doors of heaven be opened unto me ;
may Seb, the Prince 22 of the gods, open wide his two jaws unto me
; may he open my two eyes which are blindfolded; may he cause me
to stretch apart my two legs which are bound together; and may
Anpu (Anubis) make my thighs firm so that I may stand upon them.
May the goddess Sekhet make me to rise so that I may ascend unto
heaven, and may that be done which I command in the House of the
Jca (double) of Ptah (i.e., Memphis). I understand with my heart. I
have gained the mastery over my heart, I have gained the mastery
over my two hands, I have gained the mastery over my legs, I have
gained the power to do whatsoever my ka (double) pleaseth. My
soul shall not be fettered to my body at the gates of the underworld;
but I shall enter in peace and I shall come forth in peace." THE
CHAPTER OF PRESERVING THE HEART THE CHAPTER OF NOT
LETTING THE HEART (Hati) OF A MAN BE TAKEN FROM HIM IN THE
UNDERWORLD.23 Saith Osiris Ani : " Hail, ye who carry away hearts
! IJail, ye who steal hearts, and who make the heart of a man to go
through its transformations according to his deeds, let not what he
hath done harm him before you.24 Homage to you, O ye lords of
eternity, ye possessors of everlastingness, take ye not this heart of
Osiris Ani into your grasp, this heart of Osiris, and 22 Erpat, i.e.,
"tribal chief." "The Papyrus of Mes-em-neter adds: "His heart goeth
forth to take up its abode in his body, his heart is renewed before
the gods, and he hath gained the mastery over it." »« This sentence
is taken from the Papyrus of Mes-em-neter.
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176 THE SACRED BOOKS cause ye not words of evil to

spring up against it; because this is the heart of Osiris Ani,
triumphant, and it belongeth unto him of many names (i.e., Thoth),
the mighty one whose words are his limbs, who sendeth forth his
heart to dwell in his body. The heart of Osiris Ani is triumphant, it is
made new before the gods, he hath gained power over it, he hath
not been spoken to according to what he hath done. He hath got
power over his own members. His heart obeyeth him, he is the lord
thereof, it is in his body, and it shall never fall away therefrom. I,
Osiris, the scribe Ani, victorious in peace, and triumphant in the
beautiful Amenta and on the mountain of eternity, bid thee to be
obedient unto me, in the underworld." THE CHAPTER OF
PRESERVING THE HEART 25 THE CHAPTER OF NOT LETTING THE
HEART OF THE OVERSEER OF THE PALACE, THE CHANCELLOR-IN-
CHIEF, Nu, TRIUMPHANT, BE CARRIED AWAY FROM HIM IN THE
UNDERWORLD. He saith : "Hail, thou Lion-god! I am the Flower
Bush (Unb). That which is an abomination unto me is the divine
block. Let not this my heart (hati) be carried away from me by the
fighting gods in Annu. Hail, thou who dost wind bandages round
Osiris and who hast seen Set ! Hail, thou who returnest after smiting
and destroying him before the mighty ones ! This my heart (ab)
sitteth and weepeth for itself before Osiris ; it hath made
supplication for me. I have given unto him and I have decreed unto
him the thoughts of the heart in the House of the god Usekh-hra,26
and I have brought to him sand (sic) at the entry to Khemennu
(Hermopolis Magna). Let not this my heart (hati) be carried away
from me! I make thee to dwell upon this throne, O thou who joinest
together hearts (hatu) in Sekhet-hetep with years of strength
against all things that are an abomination unto thee, and to carry off
food from among the things which 25 From the Papyrus of Nu. ze
I.e., the god of the " Large Face."
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LITERATURE OF THE EAST 177 belong unto thee, and are

in thy grasp by reason of thy twofold strength. And this my heart
(hati) is devoted to the decrees of the god Tern who leadeth me into
the dens of Suti, but let not this my heart which hath done its desire
before the sovereign princes who are in the underworld be given
unto him. When they find the leg and the swathings they bury
them." THE CHAPTER OF PRESERVING THE HEART THE CHAPTER
OF NOT LETTING THE HEART OF A MAN BE TAKEN AWAY FROM
HIM IN THE UNDERWORLD. Osiris Ani, triumphant, saith: " Turn
thou back, O messenger of every god ! Is it that thou art come to
carry away this my heart which liveth ? But my heart which liveth
shall not be given unto thee. As I advance, the gods barken unto my
offerings, and they all fall down upon their faces in their own
places." THE CHAPTER OF PRESERVING THE HEART » THE
CHAPTER OF NOT ALLOWING THE HEART OF AMENHETEP,
TRIUMPHANT, TO BE CARRIED AWAY DEAD IN THE UNDERWORLD.
The deceased saith: " My heart is with me, and it shall never come
to pass that it shall be carried away. I am the lord of hearts, the
slayer of the heart. I live in right and truth (Maat) and I have my
being therein. I am Horus, the dweller in hearts, who is within the
dweller in the body. I live in my word, and my heart hath being. Let
not my heart be taken away from me, let it not be wounded, and
may neither wounds nor gashes be dealt upon me because it hath
been taken away from me. Let me have my being in the body of my
father Seb, and in the body of my mother Nut. I have not done that
which is held in abomination by the gods ; let me not suffer defeat
there, but let me be triumphant." *f From the Papyrus of Amen-
hetrp. VOL. II.— 12.
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178 THE SACRED BOOKS THE HEART OF CARNELIAN 28

THE CHAPTER OF A HEART OF CARNELIAN. Osiris Ani, triumphant,
saith: " I am the Bennu, the soul of Re, and the guide of the gods in
the Tuat (underworld). Their divine souls come forth upon earth to
do the will of their leas; let, therefore, the soul of Osiris Ani come
forth to do the will of his ka." PRESERVING THE HEART THE
CHAPTER OF NOT LETTING THE HEART OF A MAN BE DRIVEN
AWAY FROM HIM IN THE UNDERWORLD. Osiris Aufankh,
triumphant, born of Sheret-Amsu, triumphant, saith: " My heart, my
mother ; my heart, my mother ! My heart of my existence upon
earth. May naught stand up to oppose me in judgment; may there
be no opposition to me in the presence of the sovereign princes ;
may no evil be wrought against me in the presence of the gods ;
may there be no parting of thee from me in the presence of the
great god, the lord of Amentet. Homage to thee, O thou heart of
Osiriskhent-Amentet ! Homage to you, O my reins ! Homage to you,
O ye gods who dwell in the divine clouds, and who are exalted (or
holy) by reason of your scepters ! Speak ye fair words for the Osiris
Auf-ankh, and make ye him to prosper before Nehebka. And behold,
though I be joined unto the earth, and am in the mighty innermost
part of heaven, let me remain on the earth and not die in Amentet,
and let me be a khu therein forever and ever." THIS CHAPTER
SHALL BE RECITED OVER A BASALT SCARAB, WHICH SHALL BE SET
IN A GOLD SETTING, AND IT SHALL BE PLACED INSIDE THE HEART
OF THE MAN FOR WHOM THE CEREMONIES OF " OPENING THE
MOUTH " AND OF ANOINTING WITH UNGUENT HAVE BEEN
PERFORMED. AND THERE SHALL BE RECITED BY WAY OF A
MAGICAL CHARM THE WORDS I " MY HEART, MY MOTHER; MY
HEART, MY MOTHER! MY HEART OF TRANSFORMATIONS." 28 From
the Papyrus of Ani.
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LITERATURE OF THE EAST 179 PRESERVING THE HEART

THE CHAPTER OF NOT LETTING THE HEART OF THE OVERSEER OF
THE PALACE, THE CHANCELLOR-IN-CHIEF, NU, TRIUMPHANT, BE
DRIVEN AWAY FROM HIM IN THE UNDERWORLD. He saith : " O my
heart, my mother ; O my heart, my mother ! O my heart of my
existence upon earth. May naught stand up to oppose me in
judgment in the presence of the lords of the trial ; let it not be said
of me and of that which I have done, ' He hath done deeds against
that which is right and true ' ; may naught be against me in the
presence of the great god, the lord of Amentet. Homage to thee, O
my heart ! Homage to thee, O my heart! Homage to you, O my
reins! Homage to you, O ye gods who dwell in the divine clouds, and
who are exalted (or holy) by reason of your scepters! Speak ye for
me fair things to Re, and make ye me to prosper before Nehebka.
And behold me, even though I be joined to the earth in the mighty
innermost parts thereof, let me remain upon the earth and let me
not die in Amentet, but become a Khu therein." PRESERVING THE
HEART THE CHAPTER OF NOT LETTING THE HEART OF OSIRIS,
THE SCRIBE OF THE HOLY OFFERINGS OF ALL THE GODS, ANI,
TRIUMPHANT, BE DRIVEN FROM HIM IN THE UNDERWORLD. He
saith: " My heart, my mother ; my heart, my mother I My heart
whereby I came into being ! May naught stand up to oppose me at
my judgment ; may there be no opposition to me in the presence of
the sovereign princes (Tchatcha) ; may there be no parting of thee
from me in the presence of him that keepeth the Balance ! Thou art
my lea, the dweller in my body ; the god Khnemu who knitteth and
strengthened my limbs. Mayeat thou come forth into the place of
happiness whither we go. May the Shenit (i.e., the divine officers of
the court
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180 THE SACRED BOOKS of Osiris), who form the

conditions of the lives of men, not cause my name to stink. Let it be
satisfactory unto us, and let the listening be satisfactory unto us,
and let there be joy of heart unto us at the weighing of words. Let
not that which is false be uttered against me before the great god,
the lord of Amentet. Verily how great shalt thou be when thou risest
in triumph ! " RUBRIC THESE WORDS ABE TO BE SAID OVEE A
SCARAB OF GREEN STONE ENCIRCLED WITH A BAND OF REFINED
COPPER AND HAVING A RING OF SILVER, WHICH SHALL BE PLACED
ON THB NECK OF THE EHU. THIS CHAPTER WAS FOUND IN THE
CITY OF KHEMENNU (HERMOPOLIS MAGNA) UNDER THE FEET OF
THE STATUE OF THIS GOD. IT WAS INSCRIBED UPON A SLAB OF
IRON OF THE SOUTH, IN THE WRITING OF THE GOD HIMSELF, IN
THE TIME OF THE MAJESTY OF THE KING OF THE NORTH AND OF
THE SOUTH, MEN-KAU-RE,29 TRIUMPHANTLY, BY THE ROYAL SON
HERU-TA-TA-F, WHO DISCOVERED IT WHILE HE WAS ON HIS
JOURNEY TO MAKE AN INSPECTION OF THE TEMPLES AND OF
THEIR ESTATES. BEATING BACK THE CROCODILE THE CHAPTER OF
BEATING BACK THE CROCODILE THAT COMETH TO CARRY AWAY
THE CHARM FROM N"u, THE OVERSEER OF THE PALACE, THE
CHANCELLOR-IN-CHIEF, TRIUMPHANT, THE SON OF THE OVERSEER
OF THE PALACE, AMENHETEP, TRIUMPHANT, IN THE
UNDERWORLD. He Saith ! " Get thee back, return, get thee back,
thou crocodile-fiend Sui ; thou shalt not advance to me, for I live by
reason of the magical words which I have by me. I do not utter that
name of thine to the great god who will cause thee to come to the
two divine envoys.; the name of the one is Betti,30 and the 2» I.e.,
Mycerinus, a king of the Fourth Dynasty. «o/.e., "He of two teeth"
(or two horns) ; the Saite Recension reads Bent, i.e., " ape."
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