Children entering Tennessee DCS custody get a health screening within 72 hours, and the screening provider documents it on this short form. The provider either confirms the child has no apparent need for immediate medical care and no infectious or contagious disease, or lists the concerns that need immediate action, before the child's comprehensive medical examination.
The health care provider who performs the screening completes the result, details and other information, plus clinic name and address, and prints and signs their name with dates. DCS staff supply the child's name, DOB and home county.
Download the current version from the source each time; forms change without notice.
72 Hour Health Screening Report
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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Within 72 hours of a child entering DCS custody. It is a screening for urgent medical needs and infectious or contagious disease, not the full exam. The form reminds providers that the child should receive a Comprehensive Medical Examination as soon as possible.
The date of screening, then either a check that the child has no apparent need for immediate medical care and no infectious or contagious diseases, or the concerns that need immediate action with details. Other information, clinic details and the provider's printed name and signature follow.
The completed form is forwarded to the appropriate DCS Health Unit. Page 2 lists the units by region (Mid-State, West, Mid-West, Tennessee Valley, East and Northeast), the counties each serves and their child health email boxes.