STATE 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.
SDSU Children's Center
A health screening, by or under the direction of a physician must
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.
TYPE OF FACILITY
WORK DAYS PER WEEK
WORK HOURS PER DAY
Light Housekeeping. Indoor and outdoor care of young children.
TYPES OF PERSONS SERVED (Check appropriate items)
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
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)
DATE OF HEALTH SCREENING
NAME OF PHYSICIAN (PHYSICIAN’S STAMP)
HEALTH SCREENING BY: (ORIGINAL SIGNATURE)
LIC 503 (ENG/SP) (3/99) (PERSONAL)