Health Inventory - Enrollment Bright Horizons

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MARYLAND STATE DEPARTMENT OF EDUCATION
Office of Child Care
HEALTH INVENTORY
Information and Instructions for Parents/Guardians
REQUIRED INFORMATION
The following information is required prior to a child attending a Maryland State Department of Education licensed,
registered or approved child care or nursery school:
A physical examination by a physician or certified nurse practitioner completed no more than twelve months prior to
attending child care. A Physical Examination form designated by the Maryland State Department of Education and
the Department of Health and Mental Hygiene shall be used to meet this requirement (See COMAR 13A.15.03.02,
13A.16.03.02 and 13A.17.03.02).
Evidence of immunizations. A Maryland Immunization Certification form for newly enrolling children may be
obtained from the local health department or from school personnel. The immunization certification form (DHMH 896)
or a printed or a computer generated immunization record form and the required immunizations must be completed
before a child may attend. This form can be found at:
Select DHMH 896.
Evidence of Blood-Lead Testing for children living in designated at risk areas. The blood-lead testing certificate
(DHMH 4620) (or another written document signed by a Health Care Practitioner) shall be used to meet this
requirement. This form can be found at:
EXEMPTIONS
Exemptions from a physical examination, immunizations and Blood-Lead testing are permitted if the family has an
objection based on their religious beliefs and practices. The Blood-Lead certificate must be signed by a Health Care
Practitioner stating a questionnaire was done.
Children may also be exempted from immunization requirements if a physician, nurse practitioner or health department
official certifies that there is a medical reason for the child not to receive a vaccine.
The health information on this form will be available only to those health and child care provider or child care personnel
who have a legitimate care responsibility for your child.
INSTRUCTIONS
Please complete Part I of this Physical Examination form. Part II must be completed by a physician or nurse practitioner,
or a copy of your child's physical examination must be attached to this form.
If your child requires medication to be administered during child care hours, you must have the physician complete a
Medication Authorization Form (OCC 1216) for each medication. The Medication Authorization Form can be obtained at
Select OCC 1216.
If you do not have access to a physician or nurse practitioner or if your child requires an individualized health care plan,
contact your local Health Department.
OCC 1215 - Revised Aug 2015 - All previous editions are obsolete
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