DEPARTMENT OF CHILDREN AND FAMILIES dcf.wisconsin.gov/
Division of Early Care and Education
DCF-F-CFS0060-E (R. 09/2021)
Child Health Report – Child Care Centers
Use of form: Use of this form is required unless the health examination report is on an electronic printout from a licensed
physician, physician assistant, or other EPSDT provider. Completion of this form meets the requirements of DCF 202.08 (4),
DCF 250.04 (6) (a) 4. and DCF 251.04 (6) (a) 8. Failure to comply with these rules may result in issuance of a noncompliance
statement. Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04(1)(m), Wisconsin
Statutes].
Instructions: Each child under 2 years of age shall have an initial health examination not more than 6 months prior to nor later
than 3 months after being admitted to the center and a follow-up health examination at least once every 6 months thereafter.
Each child 2 years of age but who is not 5 years of age or older shall have an initial health examination not more than one year
prior to nor later than 3 months after being admitted to a center and a follow-up health examination at least once every 2 years
thereafter. The parent / guardian shall give this form to the physician, physician assistant, or other EPSDT provider to be
completed, signed, and dated. The licensee / operator shall obtain a copy for the child’s record. Note: Children are also required
to have on file at the child care center documentation of immunizations; it may be helpful if the parent / guardian includes a
copy of the child’s immunization record when submitting this form to the child care center.
P
ARENT OR GUARDIAN – This section should be completed by the parent or guardian
Child’s Name (Last, First, MI)
Child’s Birthdate (mm/dd/yyyy)
Child’s Address (Street, City, State, Zip Code)
Parent or Guardian Name (Last, First, MI)
Parent or Guardian Address (Street, City, State, Zip Code)
HEALTH PROFESSIONAL – This section should be completed by the health professional
Instructions for feeding and care of child with special health concerns – Specify: (attach information as necessary).
Yes No Does the child have a milk allergy? If “Yes,” identify the recommended milk substitute.
Yes No Does this child have any food or non-food allergies? If “Yes,” specify and include the treatment plan to be
implemented in the event of an allergic reaction.
Date of child’s most recent blood lead test:
(
mm/dd/yyyy).
Note: Children on Medicaid are required to be tested at around ages 12 months and 24 months or once between the ages of
3 and 5 years if no previous test is documented. Lead testing is optional for children who are not on Medicaid.
Immunization(s) not to be administered to child due to medical reason(s) – Specify.
I certify that I have examined the above child on this date and that he / she is able to participate in child care activities.
Name – MD, PA, or other EPSDT Provider (type or print)
Address (Street, City, State, Zip Code)
SIGNATURE – MD, PA, or other EPSDT Provider
