Maine requires nursery school licensees, administrators and staff who care for children to be declared free from communicable disease every two years. When someone applies to work in a nursery school, they bring this short statement to a clinician, who examines or certifies them and signs the declaration that the school keeps on file.
The staff member's name, address and nursery school are entered at the top, and the examining clinician signs and dates the declaration. The form's letter is addressed to the examining physician, and the rule it quotes allows a licensed physician, nurse practitioner or physician assistant.
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Nursery School Medical Statement
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Every two years. The licensing rule quoted on the form says each licensee, administrator and other staff member who provides care for children must be declared free from communicable disease every two years, and nursery schools must keep records showing compliance.
The rule quoted on the form allows a licensed physician, nurse practitioner or physician assistant to make the declaration, even though the signature line is printed with M.D. The signer adds their address and the date.
The form asks the clinician to examine and/or certify that the individual is free from communicable disease. It has no exam findings section; the clinician signs one declaration that the person was examined and is free from communicable disease.