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* 1. Date of playroom visit 

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* 2. How many children are registered in the Playroom?

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* 3. How many children do not attend the play group or playroom

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* 4. Building Name

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* 5. How many playroom or play groups sessions were hosted this month

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* 6. How many children attended the play group or playroom in this session

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* 7. What activities do children engage in at the play group or Playroom

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* 8. How many children incidents were reported in this building this month

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* 9. When did the incidents involving children occur

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* 10. Types of incidents

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* 11. Ages of children involved in incidents

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* 12. CDC view on incidents involving children

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* 13. Support System in place to address children related incidents

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* 14. Any other comments

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