Ocfs-Ldss-4433 - Medical Statement Of Child In Childcare - New York State Office Of Children And Family Services Page 2
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2OCFS-LDSS-4433 (Rev. 7/2005) REVERSE
OCFS-LDSS-4433 (Rev. 7/2005) REVERSE
Medical Statement of Child in Childcare
Medical Statement of Child in Childcare
(cont.)
(cont.)
Summary of Physical Exam
Include special recommendations to Day Care Providers
On the basis of my findings as indicated above and on my knowledge of the named child, I
find that: he/she is free from contagious and communicable disease and is able to
Yes
No
participate in day care.
Signature of Examiner
Address
Please Print Name
City, State, Zip
(
)
Title
Phone
Date
Religious Exemptions
In accordance with Public Health Law, the sincere religious beliefs of the child’s parents prohibit
Yes
No
immunization. Do you wish to exercise those rights?
Any child not fully immunized for any reason must be excluded from care whenever there is an
outbreak. The child may return only upon approval of the local county health department.
Signature of Parent or Person Legally Responsible
Date
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