NC Staff Health Assessment/Medical Report (Centers)

North Carolina child care centers need a statement, completed by a health care professional before employment, that each staff member is emotionally and physically fit to care for children. The one-page form asks four yes or no questions about limiting conditions, treatment, medications and overall capability, and the center files it in the staff member's medical file.

Who completes it

The staff member provides their name and contact details. A health care professional completes the assessment questions and signs with their address and phone.

Submitting and payment

How to submit it
The completed form goes to the center, which keeps it in the staff member's medical file, separate from the personnel file. It must have been completed within the last twelve months.
Who pays
The form sets no fee and does not say whether the center or the employee pays for the assessment.

Good to know

  • The four questions ask about physical conditions limiting work with children, current treatment, medications affecting work, and whether the person is emotionally and physically capable of daily child care.
  • Any yes answer to the first three questions needs a short description on the form.
  • The form applies to child care centers under 10A NCAC 09 .0701, and the separate medical file requirement comes from .0701(d).
  • Centers pair it with the Tuberculosis Screening Form; the current version was updated December 2022.

Get the official form

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

Staff Health Assessment/Medical Report

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.

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

How recent must the North Carolina staff health assessment be?

The form states it must have been completed within the last twelve months, and it is completed by a health care professional prior to employment to show the person is emotionally and physically fit to care for children.

Where does a North Carolina center keep the staff health assessment?

In the staff member's medical file, which must be maintained separately from the individual personnel file in the center, under child care rule 10A NCAC 09 .0701(d). The same separate medical file holds the staff member's Tuberculosis Screening Form.

Is the staff health assessment the same as the TB screening?

No. Child care staff also need the separate Tuberculosis Screening Form, administered by a licensed health care professional before contact with children. The staff health assessment covers general emotional and physical fitness only.