South Dakota Child Protection Services asks foster and adoptive parent applicants for this two-sided health report. The clinician's opinion on whether the applicant is free from physical or mental illness that might be detrimental to the care of children is described on the form as a governing factor in approval, and the information is used only for licensing or approval.
A physician, physician assistant or certified nurse practitioner completes Part A, the physical exam section, and signs. The applicant may complete Part B on the back, the immunization record for their own children under 18, and signs it.
Download the current version from the source each time; forms change without notice.
Health Report (Foster/Adoptive Parent Health Report)
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.
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Part A must be completed by a physician, physician's assistant or certified nurse practitioner. The clinician prints their name, signs as MD, PA or CNP and dates the form after answering the questions on chronic illness, medications, general health and factors affecting child care.
Yes. The note to the medical professional says a physical exam given to the applicant within one year before the application is acceptable for meeting the requirement. Enter the date the applicant was seen at the top of Part A.
An immunization record for the applicant's own children under 18, which the applicant may complete with dates for polio, Hib, MMR, hepatitis B and DTP and then sign. South Dakota law allows medical and religious exemptions, which are raised with the licensing worker.