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Massachusetts EEC Family Child Care Medical Form

The Massachusetts Department of Early Education and Care requires everyone who will care for children in their home, or work as an assistant in a licensed family child care home, to be examined by a physician or health care professional. The patient brings this form to the visit and submits it as part of their licensing or certification paperwork.

Who completes it

The physician or health care professional fills out the whole form, including the patient's name, date of birth and address, and signs it with their printed name, address, telephone and license number. The patient then submits it to EEC.

Submitting and payment

How to submit it
The clinician fills out the form in its entirety and returns it to the patient, who includes it with the licensing or certification application.
Who pays
EEC sets no fee on the form and does not say who pays for the examination.

Good to know

  • The letter to the clinician explains the context: EEC lets a licensee or certified assistant care for up to eight children under fourteen alone if two of them are school age.
  • The clinician describes the patient's general physical and mental health and any limitations, such as medication side effects or inability to lift, that would affect work with young children.
  • The form asks whether the clinician is the treating provider and for how long, or how many times they have seen the patient.
  • EEC posts the form as both a PDF and an editable Word document on its family child care licensing forms page.

Get the official form

Download the current version from the source each time; forms change without notice.

Family Child Care Medical Form

Official pagePDF

Fill it with Vero

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.

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How this list is checked

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.

Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.

Frequently asked questions

What immunization question is on the EEC family child care medical form?

The form asks whether the person has been immunized in accordance with Department of Public Health requirements for measles, mumps and rubella. The clinician can also indicate whether the patient should be medically exempted from proving immunity because re-vaccination may be contraindicated.

Who needs the Massachusetts family child care medical form?

EEC requires it for all persons who will be caring for children in their homes and for anyone working as an assistant in a licensed family child care home. It is part of the licensing or certification requirement for these roles.

Does the clinician send the EEC medical form to the state?

No. The letter at the top asks the physician or health care professional to fill out the form in its entirety and return it to the patient, who submits it as part of their licensing or certification requirement.