missouri department of health and senior services
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section for child care regulation
MEDICAL EXAMINATION REPORT FOR CAREGIVERS AND STAFF
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patient may:
have contact with children (infant through school-age) in care away from their own homes.
✔
be responsible for children’s physical care and social development during day and/or nighttime hours.
✔
need to lift children.
✔
IDENTIFYING INFORMATION (To be completed by patient.)
name
birthdate
address (street, city, state, zip code)
telephone number
(
)
name and address of child care facility where employed
MEDICAL REPORT (To be completed by a licensed physician or advance practice nurse; by registered professional nurse or
registered nurse who is under the supervision of a licensed physician.)
on _______________________ (date), i examined this patient. i certify that to the best of my knowledge, this patient
PHYSICAL
EXAMINATION
is in good physical and emotional health and free of contagious disease.
yes
no
(check one.)
tb risk assessment form attached (required)
TB CLEARANCE
a chest x-ray or appropriate written follow-up of a previous examination that indicates the individual is free of
contagion dated _____________________________________ .
the above dated physical examination indicates this patient has the following physical or mental conditions that might
endanger the health of children or might prevent the patient from providing adequate care of children:
LIMITATIONS
none
_______________________________________________________________________________________
this patient has the following restrictions, e.g., cannot lift children who weigh more than 20 pounds, etc.
RESTRICTIONS
none
_______________________________________________________________________________________
REMARKS
SIGNATURES
signature of physician or registered nurse under
date
physician’s or nurse’s name (please print.)
supervision of a physician
name and address of clinic, group practice, other
if nurse is supervised by physician, indicate physician’s name.
(please use stamp, if available)
(please print.)
telephone number
(
)
this form is to be kept on file at the child care facility
mO 580-1879 (6-14)
BCC-4