Fillable STAFF HEALTH REPORT CHILD CARE PROVIDER (Northeast Wisconsin Technical College)

Fill Online, Printable, Fillable, Blank STAFF HEALTH REPORT CHILD CARE PROVIDER (Northeast Wisconsin Technical College) Form

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

STAFF HEALTH REPORT CHILD CARE PROVIDER (Northeast Wisconsin Technical College)

On average this form takes 4 minutes to complete

The STAFF HEALTH REPORT CHILD CARE PROVIDER (Northeast Wisconsin Technical College) form is 1 page long and contains:

  • 0 signatures
  • 12 check-boxes
  • 10 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Northeast Wisconsin Technical College

BROWSE NORTHEAST WISCONSIN TECHNICAL COLLEGE 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
 
DEPARTMENT OF CHILDREN AND FAMILIES
Division of Early Care and Education
DCF-F (CFS-0054) (R. 02/2009)
STATE OF WISCONSIN
STAFF HEALTH REPORT – CHILD CARE PROVIDER
Use of form: This form is mandatory. When completed and on file, it meets the requirements of DCF 250.04(5)(e) and DCF 251.05(1)(L)1.
of the Wisconsin Administrative Code. Failure to obtain a completed form for placement in the staff file may result in enforcement action.
Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04(1)(m), Wisconsin Statutes].
Instructions: The examining health professional will complete this form, sign Sections B and C and return the completed form to the child
care provider for placement in the staff file.
A. PROVIDER INFORMATION
Name – Child Care Provider (Last, First, MI)
Position Title
B. TUBERCULOSIS TEST – MANTOUX Tuberculin Skin Test OR QuantiFERON Blood Assay for M. Tuberculosis
Date of Test (mm/dd/yyyy)
Risk Classification
Low risk Medium risk Potential ongoing transmission
Millimeters of Induration
5mm 10 mm 15mm
Results of Test
Positive Negative
If positive, what were the results of the follow-up medical evaluation?
Positive Negative
Was a chest X-ray completed?
Yes No
SIGNATURE – MD, PA or Health Check Provider
Name – Examining Health Professional (Type or Print)
Address – Health Professional Office (Street, City, State, Zip)
Date Signed (mm/dd/yyyy)
C. PHYSICAL EXAM
1. I certify, based upon my examination, that this person appears free of symptoms of illness or communicable disease that
may be transmitted through normal contact.
2. I certify, based upon my examination, that this person appears to be physically able to work with children.
NOTE: This individual will be in contact with children receiving child care services and may be responsible for the physical
care and social development of young children during the hours child care is provided. Some lifting of young children may
be required.
3. Comments:
SIGNATURE – MD, PA or Health Check Provider
Name – Examining Health Professional (Type or Print)
Address – Health Professional Office (Street, City, State, Zip)
Examination Date (mm/dd/yyyy)
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

STAFF HEALTH REPORT CHILD CARE PROVIDER (Northeast Wisconsin Technical College)

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 10 October 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document