Missouri licensed child care facilities keep a medical examination report on file for each infant, toddler and preschool child. On this one-page DESE form the examiner certifies, based on history and a physical exam within the last 12 months, that the child can participate in a child care program, and writes instructions for any specialized care the child needs.
A physician, or a registered nurse under a physician's supervision, completes and signs the form; when a nurse signs, the supervising physician's name is entered. The child's name and birthdate appear in the identifying section.
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Child Medical Examination Report (Infant/Toddler/Pre-School)
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The form states the date of the medical examination must be within the last 12 months. The examiner enters the exam date in the certification that the child can participate in a child care program.
The signature line is for a physician or a registered nurse under the supervision of a physician. If a nurse signs, the form asks for the supervising physician's name, along with the clinic or practice name and address, which may be stamped.
No. DESE says its sample forms are not required to be submitted to the Office of Childhood but must be kept on file at the facility, and the form itself is marked to be filed in the child's record at the child care facility.