Materials Waiver Submission Checklist (accessible)

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1		#VALUE!
2		Materials Waiver Submission Requirement Checklist
3		Relevant instructions are in the Materials Waivers Submission Guide

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5	1	Educational Philosophy and Rationale	Program	Choking Hazards	Glass Hazards	Sharp Objects
6	1.1	Rationale Description (1 page each, max)
7	1	Progressive/Alternative Philosophy	☐
8	2	Infant Classrooms (6 weeks - 18 months)			☐
9	3	Toddler Classrooms (12 months - 3 years)			☐
10	4	Preschool/Mixed Age Classrooms (2.5 - 7 years)		☐	☐	☐
11	1.2	Liability
12	1	Parental Consent Form	☐
13	2	Program Liability Release Form	☐
14	3	Supervisory Evaluator Attestation	☐
15	2	Qualified Staff	Program	Choking Hazards	Glass Hazards	Sharp Objects
16	2.1	Lead Teacher Qualifications
17		ECT Qualification Certificate	☐
18		Teaching Experience Verification (if applicable)	☐
19		Program Specific Observation Verification (if applicable)	☐
20	2.2	Pre-Service Training (6 hours)
21	1	Pre-Service Training Content	☐
22	2	Pre-Service Training Certificates	☐
23	3	Pre-Service Training Policies and Procedures	☐
24	2.3	Annual Refresher Training (2 hours)
25	1	Annual Refresher Training Content	☐
26	2	Annual Refresher Training Certificates	☐
27	3	Annual Refresher Training Policies and Procedures	☐
28	2.4	CPR/First Aid Certified Staff
29	1	Staff Roster	☐
30	2	Training Certificates	☐
31	3	Staffing Plan	☐
32	3	Deliberately Prepared, Safe Environments	Program	Choking Hazards	Glass Hazards	Sharp Objects
33	3.1	Oddly Shaped Classrooms (if applicable)
34	1	Number of Oddly Shaped Classrooms: [Blank Field]	☐
35	2	Classroom Layout	☐
36	3	Supervision Plan	☐
37	3.2	Policies and Procedures
38	1	Taking materials out		☐	☐	☐
39	2	Using materials		☐	☐	☐
40	3	Returning materials to storage		☐	☐	☐
41	4	Glass Clean-Up Protocol			☐
42	4	Constructive, Purposeful Play	Program	Choking Hazards	Glass Hazards	Sharp Objects
43	4.1	Lesson Plan Examples
44	1	Developmental Appropriate Use		☐	☐	☐
45	2	Lesson Sequence		☐	☐	☐
46	3	Safety Lesson		☐	☐	☐
47	4.2	Policies and Procedures
48	1	Individualized Assessment Procedures and Practice		☐	☐	☐
49	2	Assessment Documentation Procedures and Practice		☐	☐	☐
50	3	Response to Challenging Behaviors	☐
51	4	Redirection Plan	☐
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