Tennessee DCS uses this one-page report for foster parent applicants and other adults living in the home. The person first records smoking, alcohol, medical, vaccine and mental health history; a medical professional then documents TB risk or test results, conditions that would affect caring for a child, and whether they recommend the person as a foster or adoptive parent.
A physician, nurse practitioner or physician assistant completes the 'To be completed by medical professional' section and signs. The foster parent or other household adult completes the smoking, medical and mental health history above it.
Download the current version from the source each time; forms change without notice.
Foster Parent/Other Adult Medical Report
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A physician, nurse practitioner or physician assistant. The signature block reads Physician/NP/PA, with printed name, signature and date, after the clinician records TB results, any conditions affecting care and the recommendation.
CS-0678 includes a statement you can check: you are not the individual's primary care provider and are completing the form based on a single exam combined with information the individual provided on the day of the exam.
Not always. The medical professional can enter a TB risk assessment date and results and/or a TB (PPD) date and results, or mark the person not at risk or low risk.