Caregiver Medical - Cortland Child Development Centers
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2LDSS-4434-1 (Rev 5/2011) Front
HOUSEHOLD MEMBERS ~DO NOT USE THIS FORM~
Caregiver Medical
(CHECK ONE)
Provider
Substitute
Volunteer
Director
Assistant
Teacher
Statement
Other Staff
(All Modalities)
INSTRUCTIONS
A signature is required on both pages of this form.
Only a health care provider (physician, physician's assistant, nurse practitioner)
may complete and sign the Medical Condition section
A registered nurse is NOT authorized to sign the Medical Condition section
Maintain
Submit
A health care provider may use an equivalent form as long as the information on
On-Site
this form is included
Applicant Name:
Date of Birth:
Typical Duties of Day Care Program
Driver of vehicle
Lifting and carrying children
Close contact with children
Food preparation
Direct supervision of children
Facility maintenance
Desk work
Evacuation of children in an emergency
Medical Condition
/
/
Date of Exam:
On the basis of my findings and on my knowledge of the above-named individual, I find that:
He/she is physically fit to provide child day
YES (symptom free)
NO (NOT symptom free)
care and perform the duties listed above.
He/she is currently not exhibiting signs or
YES (symptom free)
NO (NOT symptom free)
symptoms of a communicable disease that
could be transmitted during day care.
He/she is currently not exhibiting signs or
YES (symptom free)
NO (NOT symptom free)
symptoms suggestive of an emotional or
psychological disorder that would hinder
his/her ability to care for children.
For any “No” responses, indicate Restrictions:
Signature (physician, physician's assistant, nurse practitioner)
Name (Please PRINT clearly)
Title
(
)
-
/
/
Phone
Date
(Continued on reverse)
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