Statement Of Health Form - Dphhs Home
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2DPHHS-QAD/CCL-20B
Page 1 of 2
(Revision 08-2006)
STATE OF MONTANA
DEPARTMENT OF PUBLIC HEALTH AND HUMAN SERVICES
CHILD CARE LICENSING PROGRAM
STATEMENT OF HEALTH FORM
_________________________________________________________________________ ___________________________________
NAME: (Please Print)
Phone Number
_________________________________________________________________________ ____________________________________
Address
City, State, Zip
_____________________________________________________
______________________________________________
Social Security Number
Birth Date
______________________________________________________________________________________________________________
Facility Name
I am: [ ] A Day Care Provider
[ ] A Care Giver
[ ] A Spouse
[ ] Other Adult Living in the Home
Applicants and providers must meet certain personal health requirements. As the agency responsible for Child Care
registration/licensing, the Department of Public Health and Human Services (DPHHS) must ensure that the health of each provider
is adequate to meet the demands of the care being provided.
Please answer the following questions by entering an “X” in the appropriate box for each question.
The Child Care Licensing worker completing the licensure study and the Child Care Licensing Program Manager who issues the license will
review this form. In some cases, the answer “yes” to a question may require an evaluation or a statement from your physician or other
appropriate professional to support your responses. The answer “yes” does not mean you will automatically be denied a registration/license.
Your explanation or, if necessary, your physician’s or other appropriate professional’s statement will be taken into consideration. The
purpose of the questions is to help decide if you have health problems that may affect your ability to safely provide care. The Child Care
Worker will discuss with you the type of additional information needed. If an evaluation or statement is needed, the specialist will assist you
in completing the authorization form for your physician or other appropriate professional. Any evaluations, tests, or visits to your physician
or other professional(s) must be paid by you.
[
] Yes
[
] No During the past 3 years, have you had any disabling chronic conditions, or physical, mental, or emotional illness
requiring care from a physician, psychologist, or other professional?
If, “Yes,” please describe. Include a description of any vision or hearing problem and any limitation on
mobility. Include treatment and current status. (You may use additional paper if needed.)
[
] Yes
[
] No Do you suffer from any physical or mental health limitations which might affect your ability to provide day care?
If “Yes,” Please explain. (You may use additional paper if needed.)
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