Ccl 357 - Health Status Form For Persons 14 Years Of Age Or Older Working Or Volunteering In School Age Programs

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Kansas Department of Health and Environment
CCL.357
Rev. 1/2014
Bureau of Family Health
1000 SW Jackson, Suite 200
Topeka, KS 66612-1274
Phone: 785-296-1270 Fax: 785-296-0803
Website:
HEALTH STATUS FORM FOR PERSONS 14 YEARS OF AGE OR OLDER
WORKING OR VOLUNTEERING IN SCHOOL AGE PROGRAMS
As required by K. A. R. 28-4-590(b)(4), each operator and each staff member who has regular, ongoing contact with children or youth shall
attest to that individual’s health status on a form supplied by the department or approved by the secretary. The health status form shall indicate
if the individual has been exposed to an active case of tuberculosis or has been diagnosed with suspect or confirmed active tuberculosis. Each
individual shall update the health status form annually or more often if there is a change in the health status or if the individual has been
exposed to an active case of tuberculosis.
PLEASE PRINT.
Name of the School Age Program exactly as stated on the license.
License Number
Facility Street Address:
City
Zip Code + 4
County
First and Last Name of the Individual for which this Health Status applies:
Date of Birth (MM/DD/YYYY)
In case of emergency, program staff should contact the following person.
Relationship to you.
Their Phone Number
First and Last Name:
(
)
Please check each question. If answer is yes, please explain.
Yes
No
1.
Do you see a health care provider regularly for any health condition?
___
___
2.
Have you had any surgery in the past 3 years?
___
___
3.
Do you have any health conditions which might interfere with your care of children or youth?
___
___
4
Do you take any medications which might interfere with your care of children or youth?
___
___
5.
Do you have any chronic illness conditions that might interfere with your care of children or youth such as:
Yes
No
Yes
No
Yes
No
Headaches
___
___
Cancer
___
___
Alcoholism
___
___
Heart Disease
___
___
Diabetes
___
___
Arthritis
___
___
High Blood Pressure
___
___
Convulsions
___
___
Liver Disease
___
___
Lung Disease
___
___
Mental Illness
___
___
Other
___
___
If you answer yes to any of the above, please explain further. Attach an additional page if needed.
OVER - COMPLETE BOTH SIDES OF FORM

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