Family Child Care Medical Form - Massachusetts
[Pages:2]Family Child Care Medical Form
Dear Physician/Health Care Professional:
The Department of Early Education and Care requires that all persons who will be caring for children in their homes or working as an assistant in a licensed family child care home be examined by a physician/health care professional. EEC allows a licensee or a certified assistant to care for up to eight children under the age of fourteen without any assistance provided two of the children are school age.
Your patient, _____________________________________________________________, is required to submit this medical form as part of his/her licensing or certification requirement. Please fill out the form in its entirety and return it to your patient.
Name of patient: __________________________________________Date of birth: _____________
Address:
__________________________________________________________________
__________________________________________________________________
Date of Examination:_________________________________________
In your professional opinion what is the status of your patient's general physical and mental health?
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
In your professional opinion does your patient have any limitations (for example side effects of medication, inability to lift, etc.) that would affect his/her ability to work with young children? If yes, please provide details of any of these limitations.
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
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FCCMedicalForm20101021
Are you the patient's treating physician/health care professional? _________ If so, how long have you
been treating this patient? ____________________________________________________________
If not, how many times have you seen this patient? ________________________________________
Comments:________________________________________________________________________
Has this person been immunized in accordance with the requirements of the Department of Public Health (Mumps, Measles and Rubella)?
________ Yes
________ No
Family child care educators may be granted a medical exemption if they are able to provide documentation signed by a physician stating the specific medical exemption. Please indicate whether your patient should be medically exempted from proving immunity to these diseases based on the fact that re-vaccination may be medically contraindicated.
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_______________________________________ Signature of Physician/Health Care Professional
__________________________________ Please print your name, address, telephone number, and license number
_______________________________________ Date
__________________________________ __________________________________ ___________________________________ ___________________________________
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FCCMedicalForm20101021
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