• 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

  • DOB*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date Of Examination*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Immunizations required for entry into day care:*

  • Medical Exemption

  • The physical condition of the named child is such that one or more of the immunizations would endanger life or health.

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  • Rows
  • Rows
  • Rows
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  • Configurable list*

  • Tests

  • Tuberculin Test Date:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Mantoux Results:

  • 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
     - -
    2 digit month, 2 digit day, 4 digit year
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  • Lead Screening (Include All Dates and Results)
  • Date of 1 Year
     - -
    2 digit month, 2 digit day, 4 digit year
  • Type
  • Date of 2 Year
     - -
    2 digit month, 2 digit day, 4 digit year
  • Type

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

  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Type

  • 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.

  • Health Specifics

  • Are there allergies? (Specify)*
  • Is medication regularly taken? (Specify drug and condition)*
  • Is a special diet required? (Specify diet and condition)*
  • Are there any hearing, visual or dental conditions requiring special attention?*
  • Are there any medical or developmental conditions requiring special attention?*

  • Summary of Physical Exam

  • On the basis of my findings as indicated above and on my knowledge of the named child, I find that: he/she is free from contagious and communicable disease and is able to participate in child day care.

  • *
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  •  -

  • Religious Exemptions

  • Public Health Law Section 2164 allows a child to be religiously exempted from immunization. A written and signed statement from a parent, parents or guardian of the child stating that they object of the immunization of their child due to their sincere and genuine religious beliefs should be submitted to the daycare owner, operator or administrator who shall determine whether the statement of religious belief is acceptable.

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