Fillable PHYSICIANS REPORTCHILD CARE CENTERS

Fill Online, Printable, Fillable, Blank PHYSICIANS REPORTCHILD CARE CENTERS Form

Use Fill to complete blank online OTHERS pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

PHYSICIANS REPORTCHILD CARE CENTERS

On average this form takes 23 minutes to complete

The PHYSICIANS REPORTCHILD CARE CENTERS form is 1 page long and contains:

  • 0 signatures
  • 8 check-boxes
  • 89 other fields

Country of origin: OTHERS
File type: PDF

BROWSE OTHERS FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
I have ■■ have not ■■ reviewed the above information with the parent/guardian.
Physician:_______________________________________________ Date of Physical Exam: ___________________________________
Address:________________________________________________ Date This Form Completed: _______________________________
Telephone: ______________________________________________ Signature ______________________________________________
■■ Physician ■■ Physician’s Assistant ■■ Nurse Practitioner
DATE EACH DOSE WAS GIVEN
//
//
IMMUNIZATION HISTORY: (Fill out or enclose California Immunization Record, PM-298.)
PHYSICIAN’S REPORT—CHILD CARE CENTERS
(CHILD’S PRE-ADMISSION HEALTH EVALUATION)
PART A – PARENT’S CONSENT
(TO BE COMPLETED BY PARENT)
__________________________________________, born ________________________________ is being studied for readiness to enter
(NAME OF CHILD) (BIRTH DATE)
_________________________________________ . This Child Care Center/School provides a program which extends from _____ : ____
(NAME OF CHILD CARE CENTER/SCHOOL)
a.m./p.m. to ______ a.m./p.m. , __________ days a week.
Please provide a report on above-named child using the form below. I hereby authorize release of medical information contained in this
report to the above-named Child Care Center.
__________________________________________________________ _________________
(SIGNATURE OF PARENT, GUARDIAN, OR CHILD’S AUTHORIZED REPRESENTATIVE) (TODAY’S DATE)
PART B – PHYSICIAN’S REPORT (TO BE COMPLETED BY PHYSICIAN)
Problems of which you should be aware:
Hearing: Allergies:medicine:
Vision: Insect stings:
Developmental: Food:
Language/Speech: Asthma:
Dental:
Other (Include behavioral concerns):
Comments/Explanations:
MEDICATION PRESCRIBED/SPECIAL ROUTINES/RESTRICTIONS FOR THIS CHILD:
LIC 701 (8/08) (Confidential)
1st 2nd 3rd 4th 5th
VACCINE
POLIO (OPV OR IPV)
DTP/DTaP/
DT/Td
MMR
HIB MENINGITIS
HEPATITIS B
VARICELLA
(DIPHTHERIA, TETANUS AND
[ACELLULAR] PERTUSSIS OR TETANUS
AND DIPHTHERIA ONLY)
(MEASLES, MUMPS, AND RUBELLA)
(REQUIRED FOR CHILD CARE ONLY)
(CHICKENPOX)
(HAEMOPHILUS B)
// // // // / /
// // // // / /
// //
// // //
// //
// //
SCREENING OF TB RISK FACTORS (listing on reverse side)
■■ Risk factors not present; TB skin test not required.
■■ Risk factors present; Mantoux TB skin test performed (unless
previous positive skin test documented).
___ Communicable TB disease not present.
STATE OF CALIFORNIA
HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING
PAGE 1 OF 2
✔
✔
✔
RISK FACTORS FOR TB IN CHILDREN:
* Have a family member or contacts with a history of confirmed or suspected TB.
* Are in foreign-born families and from high-prevalence countries (Asia, Africa, Central and South America).
* Live in out-of-home placements.
* Have, or are suspected to have, HIV infection.
* Live with an adult with HIV seropositivity.
* Live with an adult who has been incarcerated in the last five years.
* Live among, or are frequently exposed to, individuals who are homeless, migrant farm workers, users of street drugs, or residents in
nursing homes.
* Have abnormalities on chest X-ray suggestive of TB.
* Have clinical evidence of TB.
Consult with your local health department’s TB control program on any aspects of TB prevention and treatment.
LIC 701 (8/08) (Confidential) PAGE 2 of 2
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

PHYSICIANS REPORTCHILD CARE CENTERS

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 17 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document