Looking for a U.s. Department Of Education Forms And Templates? Download it for free!

Health Inventory Form - Child'S Personal Record For Child Care Facilities - Maryland State Department Of Education

MARYLAND STATE DEPARTMENT OF EDUCATION

Office of Child Care

HEALTH INVENTORY

CHILD’S PERSONAL RECORD FOR

CHILD CARE FACILITIES

Child’s Name________________________________________________________________

___________________

Last

First

Middle

Birth Date

Name of Parent or Guardian _________________________________________________

____________________

Relationship

Home Address _________________________________________________________________________________________

City_______________________________________________ State _______________ Zip Code ______________________

Check Best Telephone Number to Reach You:



Home #: ________________________

Work #: ______________________

Cell #: ________________________

Dear Parent/Guardian:

Healthy children need medical and dental health supervision and should see a doctor at regular intervals. The

health check-up should include physical examination and immunizations which are necessary to keep your child

free of communicable disease.

This form requests health and individual needs information from you (Part I), which will be helpful to the

Health Practitioner in evaluating your child, and medical information, lead screening/testing and proof of age-

appropriate immunizations from your child’s Health Practitioner (Part II). This information must be completed

prior to your child being admitted to child care.

Maryland law requires you to submit proof of age-appropriate immunizations and that children less than

six years of age have appropriate screening for lead poisoning. Children who reside (or have ever

resided) in certain areas of the State (see page 4) designated as at-risk for childhood lead poisoning must

receive one or more blood lead tests at 12 and 24 months of age.

PLEASE RETURN THIS COMPLETED FORM TO:

Name of Child Care Facility:_____________________________________________________________________________

Address:______________________________________________________________________________________________

_____________________________________________________________________________________

City/Town

State

Zip Code

OCC 1215 - Revised 6/08 - All previous editions are obsolete and replaces OCC 1215A, OCC 8506 and use of DHMH896.

Page 1 of 4

Health Inventory Form - Child'S Personal Record For Child Care Facilities - Maryland State Department Of Education