Ccl 357 - Health Status Form For Persons 14 Years Of Age Or Older Working Or Volunteering In School Age Programs Page 2

Download a blank fillable Ccl 357 - Health Status Form For Persons 14 Years Of Age Or Older Working Or Volunteering In School Age Programs in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Ccl 357 - Health Status Form For Persons 14 Years Of Age Or Older Working Or Volunteering In School Age Programs with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

Please check each of the following statements:
_____Yes _____No
I am free from physical, mental, or emotional handicaps as necessary to protect the health, safety, and
welfare of the children or youth as required by K.A.R. 28-4-590(b)(1).
_____Yes _____No
When I am working or volunteering in the School Age Program, I will not be under the influence of alcohol
or illegal substances or impaired due to the use of prescription or nonprescription drugs as required by
K.A.R. 28-4-290(b)(2).
_____Yes _____No
I am free from any infectious or contagious disease as specified in K.A.R. 28-1-6 (see below) as required by
K.A.R. 28-4-590(b)(3).
_____Yes _____No
I have not been exposed to active tuberculosis.
_____Yes _____No
I have not been diagnosed with suspect or confirmed active tuberculosis.
I attest, under penalty of perjury, that to the best of my knowledge, the information provided on this Health Status Form
is true and correct.
Signature
Date Signed (MM/DD/YYYY)
ANNUAL UPDATE
Signature _____________________________________________________________________
Date Updated____________________
Signature _____________________________________________________________________
Date Updated____________________
Signature _____________________________________________________________________
Date Updated____________________
Signature _____________________________________________________________________
Date Updated____________________
K.A.R. 28-1-6
(a)
Amebiases;
(b)
Anthrax;
(c)
Chickenpox;
(d)
Cholera;
(e)
Diphtheria;
(f)
E. coli 0157:H7;
(g)
Gonorrhea;
(h)
Malaria;
(i)
Meningitis, meningococcal;
(j)
Meningitis, aseptic and other;
(k)
Mumps;
(l)
Pediculosis;
(m)
Pertusis;
(n)
Plague;
(o)
Poliomyelitis;
(p)
Rubeola;
(q)
Rubella;
(r)
Salmonellosis (nontyphoidal);
(s)
Scabies;
(t)
Shigellosis;
(u)
Staphylococcal disease;
(v)
Streptococcal disease, hemolytic;
(w)
Taeniasis (beef or pork tapeworm);
(x)
Tinea capitis and corporis (ringworm);
(y)
Tuberculosis;
(z)
Typhoid fever;
(aa)
Sexually transmitted diseases;
(bb)
Viral hepatitis type A;
OVER - COMPLETE BOTH SIDES OF FORM

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Form (404) 371-2022 - Medical Affidavit - Affidavit For Persons 70 Years Of Age Or Older Form (404) 371-2022 - Medical Affidavit - Affidavit For Persons 70 Years Of Age Or Older Legal
Form 14 - Notice Of Location Or Change In Location Of Share Register Of Listed Company Divided Into Two Or More Registers Form 14 - Notice Of Location Or Change In Location Of Share Register Of Listed Company Divided Into Two Or More Registers Legal
Pbctc Form 49 - Application For Business Tax Exemption For Disabled Persons, Widows With Minor Dependents Or Persons 65 Years Of Age Or Older - Palm Beach County Tax Collector Pbctc Form 49 - Application For Business Tax Exemption For Disabled Persons, Widows With Minor Dependents Or Persons 65 Years Of Age Or Older - Palm Beach County Tax Collector Legal
Seasonal Influenza Vaccine Program - Child Form (6mos Thru 18 Years Of Age) Seasonal Influenza Vaccine Program - Child Form (6mos Thru 18 Years Of Age) Legal
Adult Abroad General Passport Application For Canadians 16 Years Of Age Or Over Applying Outside Of Canada And From The Usa Adult Abroad General Passport Application For Canadians 16 Years Of Age Or Over Applying Outside Of Canada And From The Usa Life
Primary Health Solutions-pediatric History Form Birth To 12 Years Of Age April 2010 Primary Health Solutions-pediatric History Form Birth To 12 Years Of Age April 2010 Medical
Consent To Adoption Form - Child Over 12 Years Of Age Consent To Adoption Form - Child Over 12 Years Of Age Legal
Form Pptc 156 - Child General Passport Application For Canadians Under 16 Years Of Age Applying In Canada Or From The Usa Form Pptc 156 - Child General Passport Application For Canadians Under 16 Years Of Age Applying In Canada Or From The Usa Life
Form Ca-7 - Combined Offer Of Employment And Work Permit/age Certificate Ca-7 For Minors 16 And 17 Years Of Age Form Ca-7 - Combined Offer Of Employment And Work Permit/age Certificate Ca-7 For Minors 16 And 17 Years Of Age Legal
Form Ca-7 - Combined Offer Of Employment And Work Permit/age Certificate Ca-7 For Minors 16 And 17 Years Of Age Form Ca-7 - Combined Offer Of Employment And Work Permit/age Certificate Ca-7 For Minors 16 And 17 Years Of Age Legal

Related Categories

Parent category: Legal
Download
Go
Page of 2