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Physician's Report.pdf

lic701.pdf

🔗 Source: cdss.ca.gov

📊 Size: 87 KB

👤 Author: CDSS

⬇️ Downloads: 200

Summary

Part A - Parent's Consent

To be completed by the parent, providing consent for the release of medical information to the child care center
Includes child's name, birth date, and name of child care center
Parent's signature and date

Part B - Physician's Report

To be completed by the physician, providing medical information about the child
Includes sections on:
+ Problems of which the child care center should be aware (hearing, allergies, vision, etc.)
+ Medication prescribed, special routines, and restrictions
+ Immunization history (including vaccines such as polio, DTP, MMR, and hepatitis B)
+ Screening for TB risk factors
Physician's signature, date of physical exam, address, telephone number, and date the form was completed

TB Risk Factors

Listed on the reverse side of the form
Includes factors such as family history of TB, foreign-born families, out-of-home placements, HIV infection, and exposure to high-risk individuals.

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Description

Child's pre-admission health evaluation form for California child care centers.
Requires parent's consent and basic child information.
Used for assessing readiness to enter a child care center.

Technical Information

File Format: PDF
File Size: 87 KB
Pages: 2
Language: EN
Author: CDSS
Total Downloads: 200
Last Updated: 1 week ago

Document Overview

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Physician's Report.pdf

Summary

Description

Technical Information

Document Overview

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