New Jersey child care centers, preschools, schools and WIC programs use this standard record of a child's exam, endorsed by the state AAP chapter, the Academy of Family Physicians and the Department of Health. The provider records measurements, conditions, medications, allergies, emergency plans and screenings, and clears the child for activities unless limits are noted.
The parent completes Section I, signs consent for the provider and child care provider or school nurse to discuss the form, and indicates whether it may go to WIC. The physician, APN or PA completes and signs Section II.
Download the current version from the source each time; forms change without notice.
Universal Child Health Record
If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
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The instructions say to list ongoing medications, including those given at home if they could affect the child in care, such as seizure, cardiac or asthma medicines. Short-term antibiotics need not be listed, but long-term ones, for urinary tract infection or sickle cell prophylaxis, should be.
Yes. The instructions say the form may be used for sports or physical education clearance: check the box above the signature line and note any limits in the physical activity block. The statement clears the child for all activities, including competitive contact sports, unless noted.
No. The instructions state the immunization record must be attached for the form to be valid. A copy of the record can be attached, or the provider can transcribe dates onto a Personal Immunization Record card (IMM-9).