Gastrostomy - Tube Care: Physician'S Checklist (Child Care Facilities) State Of California - Health And Human Services Agency
Download a blank fillable Gastrostomy - Tube Care: Physician'S Checklist (Child Care Facilities) State Of California - Health And Human Services Agency 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 Gastrostomy - Tube Care: Physician'S Checklist (Child Care Facilities) State Of California - Health And Human Services Agency 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
1
2STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GASTROSTOMY - TUBE CARE:
PHYSICIAN’S CHECKLIST (CHILD CARE FACILITIES)
(CHILD’S EVALUATION FOR APPROPRIATENESS OF CARE)
PART A - AUTHORIZED REPRESENTATIVE’S CONSENT
______________________________________, born __________________, is being considered to receive gastrostomy-tube
(NAME OF CHILD)
(BIRTH DATE)
(G-tube) feeding and/or liquid medication through a G-tube at _________________________________________________.
(NAME OF CHILD CARE FACILITY)
The child would attend this program from __________ a.m./p.m. to __________ a.m./p.m. __________ days a week.
Please provide the information required below on the above-named child. I hereby authorize release of medical information
contained in this report to the above-named child care facility (center/school/family child care home).
______________________________________________
______________________
(SIGNATURE OF CHILD’S AUTHORIZED REPRESENTATIVE)
(DATE)
PART B - INFORMATION TO BE COMPLETED BY PHYSICIAN
Assessment of Stability of Child’s Medical Condition
Is the child’s medical condition stable enough for a layperson with instruction/training to safely administer G-tube feeding, and
I I
I I
liquid medication through a G-tube (if applicable), to the child in a child care setting?
Yes
No
Please explain: __________________________________________________________________________________________
Designation of Person to Provide Instruction on G-Tube Care
If the answer to the above question is yes, each person who administers G-tube care to the child must be instructed on how to
provide that care by a competent person designated by the child’s physician. Please indicate the person you designate to provide
this instruction with regard to the above-named child (may be the child’s authorized representative):
Name _________________________________________________________
Phone Number(s):_______________________
Address _______________________________________________________________________________________________
Title or Relationship to Child: _______________________________________________________________________________
Medical Assessment (same information as on the LIC 701 for centers)
A medical assessment is required for all children who receive G-tube care at a child care facility (including a family child care
home). Please complete the following information for the above-named child. (A completed LIC 701, “Physician’s Report - Child
Care Centers,” may be attached for a child who attends a child care center.)
PROBLEMS OF WHICH YOU SHOULD BE AWARE:
HEARING:
ALLERGIES:
MEDICINE:
VISION:
INSECT STINGS:
DEVELOPMENTAL:
Food:
LANGUAGE/SPEECH:
ASTHMA:
OTHER:
OTHER (INCLUDE BEHAVIORAL CONCERNS):
COMMENTS/EXPLANATIONS:
MEDICATIONS PRESCRIBED/SPECIAL ROUTINES/RESTRICTIONS FOR THIS CHILD:
LIC 701A (9/00)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Cdph 8391 - Report Of Name Or Address Change - State Of California-health And Human Services Agency
Legal
Application For A Child Care Center License - State Of California - Health And Human Services Agency
Legal
Family Child Care Home Addendum To Notification Of Parents' Rights (regarding Removal/exclusion) State Of California - Health And Human Services Agency
Legal
Confidential Report Of Suspected Dependandent Adult / Elder Abuse - State Of California - Health And Human Services Agency
Legal
Roster Of Participants - For Vendor Use Only- Ictp Or Ceu Courses - State Of California - Health And Human Services Agency
Legal
Form Qr 3 - Mid-quarter Status Report For Cash Aid And Food Stamps - 2006 - State Of California - Health And Human Services Agency
Legal
Related Categories
Parent category: Legal