MO 580-1879 (6-14)
THIS FORM IS TO BE KEPT ON FILE AT THE CHILD CARE FACILITY
BCC-4
MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES
SECTION FOR CHILD CARE REGULATION
MEDICAL EXAMINATION REPORT FOR CAREGIVERS AND STAFF
Patient may: ✔ Have contact with children (infant through school-age) in care away from their own homes.
✔ Be responsible for childrenʼs physical care and social development during day and/or nighttime hours.
✔ Need to lift children.
IDENTIFYING INFORMATION (To be completed by patient.)
MEDICAL REPORT (To be completed by a licensed physician or advance practice nurse; by registered professional nurse or
registered nurse who is under the supervision of a licensed physician.)
SIGNATURES
NAME BIRTHDATE
ADDRESS (STREET, CITY, STATE, ZIP CODE) TELEPHONE NUMBER
( )
NAME AND ADDRESS OF CHILD CARE FACILITY WHERE EMPLOYED
PHYSICAL
EXAMINATION
TB CLEARANCE
LIMITATIONS
RESTRICTIONS
REMARKS
On _______________________ (date), I examined this patient. I certify that to the best of my knowledge, this patient
is in good physical and emotional health and free of contagious disease. Yes No
(Check one.)
TB Risk Assessment Form attached (required)
A chest x-ray or appropriate written follow-up of a previous examination that indicates the individual is free of
contagion dated _____________________________________ .
The above dated physical examination indicates this patient has the following physical or mental conditions that might
endanger the health of children or might prevent the patient from providing adequate care of children:
None
_______________________________________________________________________________________
This patient has the following restrictions, e.g., cannot lift children who weigh more than 20 pounds, etc.
None
_______________________________________________________________________________________
SIGNATURE OF PHYSICIAN OR REGISTERED NURSE UNDER DATE PHYSICIANʼS OR NURSEʼS NAME (PLEASE PRINT.)
SUPERVISION OF A PHYSICIAN
NAME AND ADDRESS OF CLINIC, GROUP PRACTICE, OTHER IF NURSE IS SUPERVISED BY PHYSICIAN, INDICATE PHYSICIANʼS NAME.
(PLEASE USE STAMP, IF AVAILABLE) (PLEASE PRINT.)
TELEPHONE NUMBER
( )
