Medical Report For Child Care printable pdf download

MARYLAND STATE DEPARTMENT OF EDUCATION

Office of Child Care

MEDICAL REPORT FOR CHILD CARE

Name of Person being evaluated: ____________________________________ Date of Birth: ___________

Name of Child Care Applicant/Provider/Facility: _________________________________________________

Address of Facility: ________________________________________________________________________

Dear Health Practitioner:

The person to be evaluated either provides (or plans to provide) child care services or lives in a home where

family child care is (or will be) given.

1) RESTRICTED OR REQUIRE SPECIAL CONDITIONS from contact with children in care due to having any

of the following:

a) Communicable disease: ___________________________________________________________

b) Chronic medical condition or physical impairment: _____________________________________

c) Vision/Hearing/Speech Disorder: ___________________________________________________

d) Nervous or Emotional Disorder: ____________________________________________________

e) Drug or Alcohol Abuse: __________________________________________________________

f) Immunization status: _____________________________________________________________

2) Tuberculosis Screening: (if needed or required by the Local Health Officer.)

Type of test: ________________ Results: ________________ Date: _________________

Answer question 3 if the person being evaluated provides (or plans to provide) child care services:

Persons who provide child care services must be able to participate fully in a program for active young children.

This includes lifting infants and young children, getting up and down from the floor, lively outdoor activities,

and moving furniture. It may also include transporting children in a motor vehicle.

3) Describe medical limitation(s) or medication(s) the person is taking, that may impair the person’s ability to perform

care-related activities, such as the ones noted above.

_________________________________________________________________________________________

___________________________________________ __________________

_______________________

Signature of Physician, CNP, RPA

Date

Phone Number

STAMP, PRINT, OR TYPE: Name and Address of Physician, Certified Nurse Practitioner, Registered Physician’s Assistant.

OCC 1204 - Revised 6/08 - All previous editions obsolete and replaces OCC 1258.

Medical Report For Child Care