Ocfs-Ldss-4433 - Medical Statement Of Child In Childcare - New York State Office Of Children And Family Services
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2OCFS-LDSS-4433 (Rev. 7/2005) FRONT
NEW YORK STATE
OFFICE OF CHILDREN AND FAMILY SERVICES
Medical Statement of Child in Childcare
To Be Completed By Licensed Physician, Physician’s Assistant or Nurse Practitioner
Name of Child:
Date of Birth:
Date of Examination:
Immunizations
Yes
No
Medical Exemption The physical condition of the named child is such that one or more of the
immunizations would endanger life or health. Attach certification specifying the exempt
immunization(s).
st
nd
rd
1
Date
2
Date
3
Date
Booster Date
Booster Date
DPT / DT
st
nd
rd
1
Date
2
Date
3
Date
Booster Date
Booster Date
Polio
st
nd
rd
th
1
Date
2
Date
3
Date
4
Date
Hib (conjugate preferred)
st
nd
rd
1
Date
2
Date
3
Date
Hepatitis B
st
nd
1
Date
2
Date
MMR
st
nd
1
Date
2
Date
Varicella / Chicken Pox
Other Immunizations
Type of Immunization:
Date:
Type of Immunization:
Date:
Tests
Tuberculin Test Date:
Mantoux Results:
Positive
Negative
mm
TB Tests are at the physician’s discretion.
If positive, or if x-ray ordered, attach physician’s statement documenting treatment and follow-up.
Lead Screening Date:
Attach lead level statement
Health Specifics
Comments
Yes
No
Are there allergies? (Specify)
Is medication regularly taken?
(Specify drug and condition)
Yes
No
Is a special diet required?
Yes
No
(Specify diet and condition)
Are there any hearing, visual or dental
Yes
No
conditions requiring special attention?
Are there any medical or developmental
Yes
No
conditions requiring special attention?
ADDITIONAL INFORMATION ON REVERSE SIDE
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