Health Screening Form Page 2

Health   S creening    

(To   b e   c ompleted   b y   P hysician)  

 

____________________________________    

_______________________________  

_______________________  

Last   N ame  

 

 

 

 

First   N ame  

 

 

 

Date   o f   B irth   ( MM/DD/YYYY)  

 

As   a   U S   s ummer   c amp   e mployee,   t he   a bove   r eferenced   a pplicant   w ill   b e   l iving   i n   a   c ommunity   e nvironment   w ith   y oung   c hildren   a nd  

may   b e   d irectly   r esponsible   f or   t heir   w ell-­‐being.   I t   i s   t herefore   i mportant   t hat   w e   a re   a dvised   o f   a ny   p hysical   o r   m ental   h ealth  

problems   t hat   m ay   h ave   a   b earing   o n   t he   a pplicant’s   a bility   t o   a ccept   s uch   r esponsibilities.    

 

Please   r eview   t he   i nformation   p rovided   b y   t he   a pplicant   o n   P age   1   o f   t his   f orm   a nd   a nswer   t he   f ollowing   q uestions.  

The   a bove   n amed   a pplicant   i s   i n   g ood   p hysical   c ondition.                    

Yes             N o                

The   a bove   n amed   a pplicant   d oes   N OT   h ave   a ny   p hysical   o r   e motional   i ssues   t hat   w ould   n egatively   a ffect   h is/her   w ork   a s   a   c amp  

counselor/support   s taff   a t   a   U S   s ummer   c amp.                             Y es               N o                

Comments:    

 

 

 

 

Please   c heck   w hether   t he   a pplicant   h ad   b een   i mmunized   a gainst   t he   f ollowing   a nd   p rovide   t he   d ate   o f   i mmunization:  

Chicken   P ox   ( Varicella)  

Hepatitis   B  

TP   M antoux   t est  

Diphtheria  

€

€

€

€

 

 

 

 

Date  

 

 

 

Date  

Date  

Date  

Haemophilus  

Tetanus  

Mumps  

Typhoid  

€

€

€

€

InfluenzaeB  

 

 

 

 

 

 

 

Date  

Date  

Date  

Date  

German   M easles  

Measles    

Polio  

Whooping   C ough  

€

€

€

€

(Rubella)  

 

 

 

 

 

 

 

Date  

Date  

Date  

Date  

 

_____________________________________________________  

_______________________________________  

Signature   o f   L icensed   M edical   P ersonnel  

 

 

 

Date   ( MM/DD/YYYY)  

_____________________________________________________  

_______________________________________  

Printed   N ame  

 

 

 

 

 

 

Title  

_____________________________________________________  

_______________________________________  

Telephone  

 

 

 

 

 

 

Email  

     

 

 

 

  P age   2   o f   2

RV3   E ffective   1 2/20/2012