California LIC 503 Health Screening Report

California requires all personnel in licensed residential care facilities for the elderly, community care facilities, residential care facilities for the chronically ill and child care facilities to show their health allows them to do the work. LIC 503 records that screening, done by or under the direction of a physician, including a TB test. It is kept in the facility's personnel file.

Who completes it

The employee or licensee completes page 1 with the facility, position, duty statement and a release of medical information. A physician, PA, NP or RN performs the screening and completes page 2, signing it with an original signature.

Submitting and payment

How to submit it
Give the completed form to the employee or licensee, who files it with the facility for its personnel records.

Good to know

  • Timing depends on the facility: within 7 days after employment or up to 6 months before for RCFEs, and up to 1 year before employment for community care, chronically ill and child care facilities.
  • Page 2 asks for an evaluation of general health, ability to do the work in the duty statement, any condition hazardous to people in care, and TB test date, result and action if positive.
  • Personnel must be free from communicable disease and capable of performing assigned tasks, as the note to the physician on page 1 states.
  • The current edition is LIC 503 (6/24), used across CCLD programs; a separate LIC 503 MFHV variant also exists.

Get the official form

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

Health Screening Report - Facility Personnel

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.

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Frequently asked questions

Who can sign the California LIC 503?

The screening must be done by or under the direction of a physician. A physician, physician assistant, nurse practitioner or registered nurse can perform the screening, and the form requires the screener's original signature along with the physician's name or stamp.

How recent must a LIC 503 screening be?

For residential care facilities for the elderly, within 7 days after employment or no more than 6 months before. For community care facilities, residential care facilities for the chronically ill and child care facilities, no more than 1 year before employment.