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Infant Feeding Plan Form

*Application optimized for desktop use*

A written plan shall be maintained on file and available for the caregiver of any child less than 18 months of age.

Child's Information

Child's Date of Birth or Expected
Month
Day
Year

NOTE: Breast milk shall be gently mixed but not be shaken. Refrigerated breast milk shall be used within 24 hours. Formula or breast milk that is served, but not completely consumed or refrigerated, shall be discarded. No milk, formula, or breast milk shall be warmed in a microwave oven.

Formula

Is your child fed formula?
Yes
No
Will formula be prepared by the caregiver?
Yes
No
Will formula be prepared (mixed) at home?
Yes
No

Breast Feeding/Breastmilk

Is your child breast fed?
Yes
No
I will nurse my child at the center:
Yes
No
I will provide breast milk:
Yes
No

Feedings

Does your child take a bottle? (Note: Bottles are required to be labeled with child’s name and the current date):
Yes
No
Are there any special instructions for bottle feeding your child?
Yes
No
Can the child feed his or herself?
Yes
No
Is the bottle warmed?
Yes
No
Does your child hold their bottle?
Yes
No
Is your child using a sippy cup? (Note: Sippy cups must be labeled with the child’s name)
Yes
No
Are there any other special instructions concerning feeding your child?
Yes
No
Does your child have any problems with feeding, such as choking or spitting up?
Yes
No

Foods & Feeding Schedule

Liquids

(formula, breastmilk,100% fruit juice in a cup)

Liquids:
Liquids: Breast Feeding
Liquids: Bottle Feeding
Liquids: Cup Feedings

Semisolid Foods

(infant cereal, strained fruitsand/or vegetables)

Semi-Solids:
Semi-Solids: Breast Feeding
Semi-Solids: Bottle Feeding
Semi-Solids: Cup Feedings

Modified Table Foods

(mashed, soft, diced fruit and /or vegetables, strained meat or poultry, pieces of soft bread)

Modified Table Foods:
Modified Table Foods Spoon Feedings:

Finger Foods

(small pieces of soft/cooked table food, chopped food)

Finger Foods:
Finger Foods Spoon Feedings:

Other

Does your child take a pacifier?
Yes
No

Note: Pacifiers with straps or other types of attachment devices are not permitted. Pacifiers must be removed when the child is crawling or walking

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