LDSS-4434-1 (Rev 5/2011) Front

HOUSEHOLD MEMBERS ~DO NOT USE THIS FORM~
Caregiver Medical Statement (All Modalities) 
(CHECK ONE)   Provider     Substitute    Volunteer  
                     Director     Assistant      Teacher    
                     Other Staff
    INSTRUCTIONS

* A signature is required on both pages of this form. 
* Only a health care provider (physician, physician's assistant, nurse practitioner) may complete and sign the Medical Condition section
* A registered nurse is NOT authorized to sign the Medical Condition section
* A health care provider may use an equivalent form as long as the information on this form is included
Applicant Name: 
?????

Date of Birth:
?????
Typical Duties of Day Care Program
* Lifting and carrying children 

* Driver of vehicle  
* Close contact with children
* Food preparation  
* Direct supervision of children
* Facility maintenance

* Desk work    
* Evacuation of children in an emergency




  Medical Condition
Date of Exam:
????? /????? /?????

On the basis of my findings and on my knowledge of the above-named individual, I find that:

* He/she is physically fit to provide child day care and perform the duties listed above.
 YES (symptom free)     NO (NOT symptom free)

* He/she is currently not exhibiting signs or symptoms of a communicable disease that could be transmitted during day care.
 YES (symptom free)     NO (NOT symptom free)

* He/she is currently not exhibiting signs or symptoms suggestive of an emotional or psychological disorder that would hinder his/her ability to care for children. 
 YES (symptom free)     NO (NOT symptom free)

For any �No� responses, indicate Restrictions:  ?????

	


Signature (physician, physician's assistant, nurse practitioner) 
?????

?????
Name  (Please PRINT clearly)                                                                   

Title
( ??? ) ??? - ????

?? / ?? / ????
Phone                                                                     

Date

	(Continued on reverse)
LDSS-4434-1 (Rev. 5/2011) Reverse

HOUSEHOLD MEMBERS ~DO NOT USE THIS FORM~
Caregiver Medical Statement (All Modalities) 
(CHECK ONE)   Provider     Substitute    Volunteer  
                     Director     Assistant      Teacher    
                     Other Staff
    INSTRUCTIONS

* A health care provider (physician, physician's assistant, nurse practitioner) or a registered nurse (as part of their duties at a health care facility) may enter the Mantoux results in the TB section and sign this page

Applicant Name: 
?????

Date of Birth:
?????



Tuberculin Test Information
 
Test Read on: �����
 Not Tested  Reason: ?????

If applicant was previously Positive, indicate date: ?????

Mantoux Result:
 Positive     Negative
?????
 mm

If positive, does this person�s contact with children enrolled in child care pose a risk to the children�s health and safety?					 
  Yes    No






Signature (physician, physician's assistant, nurse practitioner OR a registered nurse) 
?????

?????
Name  (Please PRINT clearly)                                                                                                                                    

Title
( ��� ) ��� - ����

�� / �� / ����
Phone                                                                     

Date






B-2
     NYS SDCC Booklet #: 00019990APP 00014732APP