Infant Welfare In-Home Visit Observation Sheet
Visit Details
Date of Visit:
Time:
Observer Name:
Infant Name:
Caregiver Name(s):
Infant Age (months):
Address:
General Home Environment
Aspect
Comments / Observations
Cleanliness
Safety Hazards
Ventilation
Sleeping Arrangement
Feeding Area
Infant's Health & Hygiene
General Appearance:
Any Signs of Illness:
Hygiene (skin, hair, nails):
Clothing:
Nutrition & Feeding
Breastfeeding/Bottle Feeding Observations:
Solid Foods & Diet:
Feeding Schedule:
Caregiver-Infant Interaction
Interaction Aspect
Comments/Observations
Responsiveness to Needs
Emotional Involvement
Stimulation/Play
Developmental Milestones
Physical Development:
Social/Emotional Development:
Communication (sounds, babbling, gestures):
Follow-Up/Recommendations
Immediate Concerns:
Recommendations to Caregivers:
Date of Next Proposed Visit:
Observer Signature: