Pennsylvania's rules for child care centers, group homes and family homes (55 Pa. Code 3270.131, 3280.131 and 3290.131) require a health report for each enrolled child, and CD 51 is the state's form for it. A physician, CRNP or physician assistant documents health history, medications, allergies, special needs, screenings and immunizations and states whether the child can take part in child care. The facility keeps a copy in the child's record.
The parent fills in identifying details and the child care facility, signs an authorization for staff and the health professional to communicate, and may write immunization dates. The physician, CRNP or physician assistant verifies and completes all health data and signs with title and license number.
Enter the child's last and first name, date of birth, parent or guardian, home phone, address, child care facility name and phone, county and work phone. The parent checks the box authorizing child care staff and the child's health professional to communicate directly to clarify information on the form, and signs. The header notes parents may write immunization dates but the health professional should verify and complete all data.
Describe any history or medical information staff need for routine care or that would matter in an emergency, or check NONE. The form is printed 'DO NOT OMIT ANY INFORMATION', and each narrative block has a NONE box so the facility can tell a deliberate negative from a skipped question.
Describe all medication and any special diet the child receives and the reason for each, or check NONE. The form says all medications should be documented in case the child needs emergency medical care, and allows additional sheets. In the next block, describe the child's allergies, or check NONE.
List any health problems or special needs and the recommended treatment or services. Attach sheets as needed to describe the plan of care the facility should follow, including any special training staff need, equipment, and provisions for emergencies. The center regulation ties this item to abnormal vision, hearing or lead screening results, which the form records in the screening block below.
Answer Yes or No to whether, in your assessment, the child can participate in child care and appears to be free from contagious or communicable diseases. If No, explain. This statement is one of the items the center regulation requires in every health report, and certification worksheets check it for each child.
Answer whether the child has received all age-appropriate screenings in the American Academy of Pediatrics' routine preventive care schedule. Below, note abnormal results only: vision (subjective until age 3), hearing (subjective until age 4) and lead. For an abnormal screening, give the date it was done and information about referrals, implications or actions recommended for the child care facility.
Enter up to five dates each for hepatitis B, rotavirus, DTaP/DTP/Td, Hib, pneumococcal, polio, influenza, MMR, varicella, hepatitis A, meningococcal and other vaccines, with comments, or attach a copy of the record. Centers need written verification of dates for children 2 months and older within 60 days. A medical exemption requires a separate signed, dated statement from the physician, PA or CRNP.
Enter the medical care provider's name, address and phone, then sign as physician, CRNP or physician assistant, add your title and license number, and date the form. When the report is updated later, the health professional initials and dates any new data rather than starting a new form.
Download the current version from the source each time; forms change without notice.
Child Health Report
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A physician, CRNP or physician assistant. The signature line reads 'Signature of Physician, CRNP or Physician's Assistant', with fields for title, license number and date signed. The center regulation adds that the report must be completed and signed by one of these professionals and that the signature must include the person's professional title.
Under 55 Pa. Code 3270.131 for centers, parents submit an initial report within 60 days of the first day of attendance, then updated reports at least every 6 months for infants and young toddlers and at least every 12 months for older toddlers and preschoolers. School-age children's initial reports follow the school health exam rules in 28 Pa. Code 23.2.
Yes. The immunization section says to record the dates below or attach a photocopy of the child's immunization record. Parents may write immunization dates themselves, but the form states the health professional should verify and complete all data, and the center needs written verification of dates from a physician, PA, CRNP or health department.
Yes. The file DHS posts is titled CD 51 (formerly CY 51) Child Health Assessment, and the printed form is headed Child Health Report with the footer CD 51 09/08. It cites the center, group home and family home regulations (55 Pa. Code 3270.131, 3280.131 and 3290.131).