Medical Statement Template Of Child In Childcare

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OCFS-LDSS-4433 (Rev. 4/2008) FRONT
NEW YORK STATE
OFFICE OF CHILDREN AND FAMILY SERVICES
Medical Statement of Child in Childcare
To Be Completed By Licensed Physician, Physician’s Assistant or Nurse Practitioner
Name of Child:
Date of Birth:
Date of Examination:
Immunizations required for entry into day care
Yes
No
Medical Exemption The physical condition of the named child is such that one or more
of the immunizations would endanger life or health. Attach certification specifying the
exempt immunization(s).
st
nd
rd
th
th
1
Date
2
Date
3
Date
4
Date
5
Date
Diphtheria, Tetanus and
Pertussis (DPT) Diphtheria
and Tetanus and acellular
Pertussis (DTaP)
st
nd
rd
th
1
Date
2
Date
3
Date
4
Date
Polio (IPV or OPV)
st
nd
rd
th
st
1
Date
2
Date
3
Date
4
Date OR 1
Date (if given on or
Haemophilus influenzae
after 15 months of age)
type B (Hib)
st
nd
rd
th
Pnuemococcal Conjugate
1
Date
2
Date
3
Date
4
Date
(PCV) for those born on or
after 1/1/08)
st
nd
rd
1
Date
2
Date
3
Date
Hepatitis B
st
nd
1
Date
2
Date
Measles, Mumps and
Rubella (MMR)
st
nd
1
Date
2
Date
Varicella (also known as
Chicken Pox)
Other Immunizations may include the recommended vaccines of Rotavirus,
Influenza and Hepatitis A
Type of Immunization:
Date:
Type of Immunization:
Date:
Type of Immunization:
Date:
Type of Immunization:
Date:
Type of Immunization:
Date:
Type of Immunization:
Date:
Tests
Tuberculin Test Date:
/
/
Mantoux Results:
Positive
Negative
mm
TB Tests are at the physician’s discretion.
If positive, or if x-ray ordered, attach physician’s statement documenting treatment and follow-up.
Lead Screening Date:
/
/
Attach lead level statement
Lead Screening (Include All Dates and Results)
1 year
/
/
Result:
mcg/dL
Venous
Capillary
2 years
/
/
Result:
mcg/dL
Venous
Capillary
Most recent date of lead screening (if different from above):
/
/
Result:
mcg/dL
Venous
Capillary
Per NYS law, a blood lead test is required at 1 and 2 years of age and whenever risk of lead poisoning is likely.
If the child has not been tested for lead, the day care provider may not exclude the child from child day care, but must
give the parent information on lead poisoning and prevention, and refer the parent to their health care provider or the
county health department for a lead blood screening test.
ADDITIONAL INFORMATION ON REVERSE SIDE

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