Certification Form Of Health For School Personnel
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1CERTIFICATION OF HEALTH FOR SCHOOL PERSONNEL
K.S.A. 72-5213
To be completed by the Applicant/Employee:
(
)
Form to become part of the personnel file
Name:__________________________________Social Security Number ___________
Home Address: _____________________________________Birthdate:____________
(Street, City and Zip Code)
Job Title:________________________________Work Site:______________________
****************************************************************************************************
Tuberculin Testing Results
(
)
To be completed by the Health Care Professional
Tuberculosis has been ruled out by:
Test
Date of Test
Date Test Read
Result
Mantoux/PPD
___________
_____________
_____________mm induration
(
)
Positive
_____________
(
)
Negative
Chest X-Ray:
___________
_____________
_____________
(
)
Negative/Positive
Testing Conducted by: __________________________
________________________________
(
)
Health Facility
Individual Who Read Test: ______________________________________________________________
(
)
Signature
************************************************************************************************************************
Physician's Statement
I have, this date, examined __________________________and find no evidence of any physical condition that would
(Name)
conflict with the health, safety, or welfare of the pupil or would prevent the individual from working in a safety and
healthful manner. List limitations or restrictions, if any.
Comments: ___________________________________________________________________________________
___________________________________________________________________________________
_________________________________________
__________________________________________________
(Signature of Licensed Physician)
(ExaminationDate)
_____________________________________________________________________________________________
(Address)
(City)
(State)
(Zip)
This medical evaluation has been conducted under the guidelines established by K.S.A. 72-5213 as indicated below:
Certification of health; form and contents; expense of obtaining. Every board of education shall require all persons, whether
employees of the school district or under the supervision thereof, who come in regular contact with the pupils of the school district,
to submit a certification of health signed by a person licensed to practice medicine and surgery under the laws of any state on a form
prescribed by the secretary of health and environment.. The certification shall include a statement that there is no evidence of
physical condition that would conflict with the health, safety or welfare of the pupils; and that freedom from tuberculosis has been
established by chest x-ray or negative tuberculin skin test. If at any time there is reasonable cause to believe that any such person
is suffering from an illness detrimental to the health of the pupils, I the school board may require a new certification of health. The
expense of obtaining certification of health may be borne by the board of education (1980). Revised, 5/95
KSDE / School Bus Safety Unit
July 2014
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