Fillable Health Information Report printable pdf download

Division of Public Health - Licensure Unit - Children’s Services Licensing Program

Department of Health & Human Services

Health Information Report

A Health Information Report (HIR) is required to be submitted with initial applications. Staff responsible for the care and supervision of

children must complete the HIR within 30 days of hiring. The HIR must be completed annually. All blanks must be completed. If needed,

attach a separate page and clearly identify the question being answered. A positive response to a question will not necessarily prohibit

the issuance of a license or a noncompliance with licensing standards. Failure to provide accurate information may result in a violation

of regulations.

Name:

Birth Date:

Street Address:

City:

State:

Zip Code:

Telephone No.:

If applicable, indicate name and address of facility for whom you work:

Name of Facility:

Street Address:

City:

State:

Zip Code:

1. Within the past five years, have you exhibited any conduct or behavior that could call into question your ability to provide

care/services in a competent, ethical, and professional manner?  YES

 NO

If you answered YES to item #1 above, provide an explanation:

Date(s) of conduct or behavior:

2. Do you currently have any condition or impairment (including, but not limited to, substance abuse, alcohol abuse, or a

mental, physical, emotional, or nervous disorder or condition) that in any way affects your ability to provide care/services

safely and in a competent, ethical, and professional manner?  YES

 NO

3. If your answer to Question 2 is yes, are the limitations caused by your condition or impairment reduced or lessened

because you receive ongoing treatment or because you participate in a monitoring or support program?  YES

 NO

“Currently” means that the condition or impairment could reasonably affect your ability to function as a care/service

provider. If your answer to Item 2 or Item 3 above is YES, complete a separate FORM A (Authorization for Release of

Medical Information).

4. Within the past five years, have you given a condition or impairment as a defense, in mitigation, or as an explanation

for your conduct or behavior as a response to any inquiry, investigation or any administrative or judicial proceeding by a

school, government agency, professional organization, or licensing authority or in connection with an employment disci-

plinary or termination procedure?  YES

 NO

If you answered YES to Item 4 above, provide the following:

Name of entity before which the issue was raised (i.e., court, agency, etc):

Street Address:

City:

State:

Zip Code:

Nature of the proceeding:

Date(s):

Conclusion, if any:

Explanation:

I HAVE READ THE FOREGOING DOCUMENT AND HAVE ANSWERED ALL QUESTIONS FULLY. THE ANSWERS ARE COMPLETE

AND TRUE TO THE BEST OF MY KNOWLEDGE. I HAVE NOT CHANGED THE QUESTIONS IN ANY MANNER.

Signature of Applicant or Provider

Date

Distribution: WHITE COPY - OFFICE OF CHILDREN’S SERVICES LICENSING; CANARY COPY - PROVIDER

CRED-0915 9/15

Previous versions should not be used.

Health Information Report

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