Lic 503 - Authorization For Release Of Medical Information
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1STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING
HEALTH SCREENING REPORT - FACILITY PERSONNEL
All personnel, including applicant, licensee or employed staff of
Residential Care Facilities for the Elderly, Community Care or Child
Care Facilities must demonstrate that their health condition allows them
to perform the type of work required. This health appraisal is to be
completed by or under the direction of a physician.
FACILITY NAME
SDSU Children's Center
A health screening, by or under the direction of a physician must
FACILITY ADDRESS
have been performed not more than one year prior to employment
5500 Campanile Drive, San Diego, CA 92182
or within seven (7) days after employment.
PERSON'S NAME
AGE
POSITION TITLE
TYPE OF FACILITY
WORK DAYS PER WEEK
WORK HOURS PER DAY
Childcare
2-5
3-8
DUTY STATEMENT
Light Housekeeping. Indoor and outdoor care of young children.
TYPES OF PERSONS SERVED (Check appropriate items)
Infants
Adults
Developmentally Disabled
Physically Handicapped
Children
Elderly
Mentally Disordered
Drug/Alcohol Addiction
Other (specify) ______________________________________________________________________________________________
AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION
I HEREBY AUTHORIZE THE RELEASE OF MEDICAL INFORMATION CONTAINED IN THIS REPORT.
SIGNATURE OF APPLICANT/LICENSEE OR EMPLOYEE
ADDRESS
DATE
NOTE TO PHYSICIAN: Personnel in Residential Care Facilities for the Elderly, Community Care or Child Care Facilities shall be free from
communicable disease, and capable of performing assigned tasks. Please complete the following information on the above named person.
EVALUATION OF GENERAL HEALTH
EVALUATION OF ABILITY TO PERFORM WORK DESCRIBED IN THE ABOVE DUTY STATEMENT
NOTE ANY HEALTH CONDITION THAT WOULD CREATE A HAZARD TO THE PERSON, CLIENTS, CHILDREN OR OTHER PERSONNEL
DATE OF T.B. TEST
ACTION TAKEN (IF POSITIVE)
POSITIVE
NEGATIVE
DATE OF HEALTH SCREENING
NAME OF PHYSICIAN (PHYSICIAN’S STAMP)
DATE
HEALTH SCREENING BY: (ORIGINAL SIGNATURE)
TELEPHONE #
DATE
LIC 503 (ENG/SP) (3/99) (PERSONAL)
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