Children enrolled in West Virginia licensed child care need a health assessment on file, and ECE-CC-3 is the state's form for it. The clinician records growth measurements with percentiles, a system-by-system exam, immunization dates, screening results such as lead, anemia and TB, allergies, and any health problems or special care the facility needs to know about for routine care and emergencies.
An MD, DO, PA or CRNP completes the exam, immunization, screening and recommendation sections and signs. The top of the form holds the child's, parent's and facility's details.
Download the current version from the source each time; forms change without notice.
Child Health Assessment
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Yes. The form says a copy of the Health Check exam report attached to a copy of the child's immunization record may be substituted for it. If the ECE-CC-3 itself is used, the examining MD, DO, PA or CRNP completes and signs it for the facility.
Health history relevant to routine care and emergencies, food or medicine allergies, length or height, weight, head circumference and blood pressure with percentiles, a system-by-system exam including development, immunization dates, screening results, the date of the last dental exam, and any health problems with recommended treatment or special care.
The signature line is for a physician or CRNP, with check boxes for MD, DO, PA and CRNP to show the examiner's credential. The examiner also enters the medical care provider's name and address and the date of the exam.