DATE OF HEALTH SCREENING NAME OF PHYSICIAN (PHYSICIAN’S STAMP) DATE
HEALTH SCREENING BY: (ORIGINAL SIGNATURE) TELEPHONE # DATE
■■ Infants ■■ Adults ■■ Developmentally Disabled ■■ Physically Handicapped
■■ Children ■■ Elderly ■■ Mentally Disordered ■■ Drug/Alcohol Addiction
■■ Other
(specify)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
HEALTH SCREENING REPORT - FACILITY PERSONNEL
All personnel, including applicant, licensee or employed staff of
Residential Care Facilities for the Elderly, Community Care or Child
Care Facilities must demonstrate that their health condition allows them
to perform the type of work required. This health appraisal is to be
completed by or under the direction of a physician.
A health screening, by or under the direction of a physician must
have been performed not more than one year prior to employment
or within seven (7) days after employment.
FACILITY NAME
FACILITY ADDRESS
PERSON'S NAME AGE
POSITION TITLE TYPE OF FACILITY WORK DAYS PER WEEK WORK HOURS PER DAY
DUTY STATEMENT
TYPES OF PERSONS SERVED
(Check appropriate items)
AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION
I HEREBY AUTHORIZE THE RELEASE OF MEDICAL INFORMATION CONTAINED IN THIS REPORT.
SIGNATURE OF APPLICANT/LICENSEE OR EMPLOYEE ADDRESS DATE
NOTE TO PHYSICIAN:
Personnel in Residential Care Facilities for the Elderly, Community Care or Child Care Facilities shall be free from
communicable disease, and capable of performing assigned tasks. Please complete the following information on the above named person.
EVALUATION OF GENERAL HEALTH
EVALUATION OF ABILITY TO PERFORM WORK DESCRIBED IN THE ABOVE DUTY STATEMENT
NOTE ANY HEALTH CONDITION THAT WOULD CREATE A HAZARD TO THE PERSON, CLIENTS, CHILDREN OR OTHER PERSONNEL
DATE OF T.B. TEST ACTION TAKEN (IF POSITIVE)
■■ POSITIVE
■■ NEGATIVE
LIC 503 (3/99) (PERSONAL)
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