California child care centers must obtain a written medical assessment of each child before enrollment or within 30 calendar days after it (22 CCR 101220), and this two-page report from the Community Care Licensing Division is the form for it. Pediatric clinicians meet it at a pre-enrollment visit. The center uses the report to judge whether it can provide the health-related services the child needs.
A physician, physician assistant or nurse practitioner completes Part B, the Physician's Report, and checks which of the three signed it. The parent, guardian or authorized representative completes and signs Part A, which names the center, gives its hours and authorizes release of the report to it.
The parent enters the child's name and birth date, the name of the child care center or school, and the program's hours and days per week, then signs and dates. The signature authorizes release of the medical information in the report to the center. Check that Part A is signed before the report goes back, since it is the family's authorization for the center to receive it.
Note any problems with hearing, vision, development, language or speech and dental health, plus other concerns, including behavioral ones. Record allergies to medicine, insect stings and food, and asthma. Use Comments/Explanations to expand on any item noted. Regulation 101220 also asks for any infectious or contagious disease that would preclude care and the child's special problems and needs.
List prescribed medications the child takes, any special routines staff must follow and any activity or dietary restrictions. The licensing regulation names prescribed medications and the child's special needs among the required contents of the medical assessment, and the center uses this block to decide whether it can provide the health-related services the child needs.
Either fill in the date of each dose or enclose the California Immunization Record, PM-298. The grid covers polio (OPV or IPV) through five doses, DTP, DTaP, DT or Td through five doses, MMR, Hib (required for child care only), hepatitis B and varicella. Enter dates as month, day and year for each dose given.
Check one: risk factors not present, so a TB skin test is not required; or risk factors present, with a Mantoux skin test performed unless a previous positive skin test is documented, and the result entered. A further box records that communicable TB disease is not present. The risk factors are listed on the back of the form.
Check whether you have or have not reviewed the information with the parent or guardian. Enter the clinician's name, address and telephone, the date of the physical exam and the date the form was completed, then sign and check physician, physician's assistant or nurse practitioner. The exam date matters because the center cannot accept an assessment more than one year old.
The reverse lists the risk factors to screen for: a family member or contact with confirmed or suspected TB; foreign-born families from high-prevalence countries; out-of-home placement; HIV infection, or living with an adult with HIV; living with an adult incarcerated in the last five years; frequent exposure to people who are homeless, migrant farm workers, users of street drugs or nursing home residents; and chest X-ray or clinical evidence of TB.
Download the current version from the source each time; forms change without notice.
Physician's Report - Child Care Centers (Child's Pre-Admission Health Evaluation)
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The signature block offers three checkboxes: physician, physician's assistant and nurse practitioner. Title 22 Section 101220 says the medical assessment must be performed by, or under the supervision of, a licensed physician. The signer also enters the date of the physical exam and the date the form was completed, along with their name, address and telephone.
Under 22 CCR 101220, the medical assessment can be no more than one year old when the child care center obtains it, and the center must have it before enrollment or within 30 calendar days after. The Department of Social Services can also require a current assessment if one is needed to verify that the child's placement is appropriate.
Not for every child. The clinician screens for TB risk factors, which are listed on page 2. If none are present, the form records that a TB skin test is not required. If risk factors are present, a Mantoux skin test is performed unless a previous positive test is documented, the clinician records the result, and a separate box records that communicable TB disease is not present.
CDSS lists the LIC 701 (8/08) Physician's Report for child care centers only in English on its forms page. The companion parent forms, LIC 702 Child's Preadmission Health History and LIC 627 Consent for Emergency Medical Treatment, are listed on the same page.