NYS Daycare-Health-Assessment

Child In Care Medical Statement

NEW YORK STATE OFFICE OF CHILDREN AND FAMILY SERVICES
To Be Completed By Licensed Physician, Physician’s Assistant or Nurse Practitioner
Name of Child*

First NameLast Name
DOB*

MonthDayYear
Date
Date Of Examination*

MonthDayYear
Date
Immunizations required for entry into day care:*

YesNo
Medical Exemption
The physical condition of the named child is such that one or more of the immunizations would endanger life or health.
Attach certification specifying the exempt immunization(s).

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Cancelof

	1st Date	2nd Date	3rd Date	4th Date	5th Date
Diphtheria, Tetanus and Pertussis (DPT) Diphtheria and Tetanus and acellular Pertussis (DTaP)

	1st Date	2nd Date	3rd Date	4th Date
Polio (IPV or OPV)

	1st Date	2nd Date	3rd Date	4th Date OR 1st Date (if given on or after 15 months of age)
Haemophilus influenzae type B (Hib)

	1st Date	2nd Date	3rd Date	4th Date
Pnuemococcal Conjugate (PCV) for those born on or after 1/1/08)

	1st Date	2nd Date	3rd Date
Hepatitis B

	1st Date	2nd Date
Measles, Mumps and Rubella (MMR)

	1st Date	2nd Date
Varicella (also known as Chicken Pox)

Configurable list*
Tests
Tuberculin Test Date:

MonthDayYear
Date
Mantoux Results:

PositiveNegative
How Many MMs
TB Tests are at the physician’s discretion. Acceptable tests include Mantoux or other federally approved test. If positive, or if x-ray ordered, attach physician’s statement documenting treatment and follow-up.
Lead Screening Date

MonthDayYear
Date
Attach lead level statement

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Cancelof
Lead Screening (Include All Dates and Results)
Date of 1 Year

MonthDayYear
Date
Result (mcg/dL)
Type

VenousCapillary
Date of 2 Year

MonthDayYear
Date
Result (mcg/dL)
Type

VenousCapillary
Most recent date of lead screening (if different from above):
Date

MonthDayYear
Date
Result (mcg/dL)
Type

VenousCapillary
Per NYS law, a blood lead test is required at 1 and 2 years of age and whenever risk of lead poisoning is likely.

If the child has not been tested for lead, the day care provider may not exclude the child from child day care, but must give the parent information on lead poisoning and prevention, and refer the parent to their health care provider or the county health department for a lead blood screening test.

Child In Care Medical Statement