Form Lic 281a - License Application And Instructions For Child Care Centers Page 17
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37A11.
LIC 503
– HEALTH SCREENING REPORT–FACILITY PERSONNEL
(NOTE):
This form is not required, under certain circumstances, of persons who are adherents of a
well-recognized church relying solely upon prayer or spiritual means of healing. But facilities must
present satisfactory evidence to the licensing agency that the persons in question are free from any
communicable disease. This evidence must be in the form of a written statement from a practitioner
recognized by the religion for the purposes of healing.
•
This form verifies the health of the applicant(s) and the site director to ensure that they can
effectively perform duties as required.
•
One form or set of forms each is required for the applicant(s) and the director.
•
At the time of application, the health screening must be less than one year old.
•
The tuberculosis (TB) test section of the LIC 503 must be filled out, including the result. Otherwise,
a separate TB test verification is required.
•
If the applicant is a corporation, there must be a health screening (with a TB clearance) for the
board president, the chief executive officer, or the person designated by board resolution.
•
If the applicant(s) has other licensed facilities and has a health exam on file - or if the director has
worked at another facility with the same licensee and has a health exam on file - a new exam is not
required unless there are obvious health problems.
•
The LIC 503 must be signed and dated by a qualified medical professional. The licensing agency
will not accept photocopied signatures on this form.
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