Form CCL.358 "Health History for Children and Youth Attending School Age Programs" - Kansas

This version of the form is not currently in use and is provided for reference only.
Download this version of Form CCL.358 for the current year.

What Is Form CCL.358?

This is a legal form that was released by the Kansas Department of Health & Environment - a government authority operating within Kansas. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on March 1, 2017;
  • The latest edition provided by the Kansas Department of Health & Environment;
  • Easy to use and ready to print;
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  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form CCL.358 by clicking the link below or browse more documents and templates provided by the Kansas Department of Health & Environment.

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Download Form CCL.358 "Health History for Children and Youth Attending School Age Programs" - Kansas

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CCL. 358
Kansas Department of Health and Environment
Rev. 3/2017
Bureau of Family Health
Child Care Licensing Program
1000 SW Jackson, Suite 200
Topeka, KS 66612-1274
Phone: (785) 296-1270 Fax (785) 559-4244
Website: www.kdheks.gov/kidsnet
HEALTH HISTORY FOR CHILDREN AND YOUTH ATTENDING SCHOOL AGE PROGRAMS
As required by K.A.R. 28-4-590(d) (1), each operator shall obtain a health history for each child or youth, on a form supplied by the
department or approved by the secretary. Each health history is to be maintained in the child’s or youth’s file on the premises. As
required by K.A.R. 28-4-590(d)(2), each operator shall require that each child or youth attending the program has current immunizations
as specified in K.A.R. 28-1-20 or has an exemption for religious or medical reasons.
Complete one form for each child or youth attending the School Age Program.
Gender
Date of Birth
First day at this program:
First and Last Name of the Child or Youth
(M or F)
(MM/DD/YYYY)
(MM/DD/YYYY)
First and Last Name of the Child’s or Youth’s Mother or Guardian
Mother/Guardian’s Home Street Address
City
Zip Code
Home Phone #
(
)
Mother/Guardian’s Work Place Name & Street Address
City
Zip Code
Work Phone #
(
)
First and Last Name of the Child’s or Youth’s Father or Guardian
Father/Guardian’s Home Street Address
City
Zip Code
Home Phone #
(
)
Father/Guardian’s Work Place Name & Street Address
City
Zip Code
Work Phone #
(
)
Names and ages of other children in the Child or Youth’s Family (Attach additional page if needed.)
Person(s) authorized to pick up the Child or Youth in
City
Zip Code
Phone Number (during
case of emergency. Include first and last name and
program hours):
Street Address. Attach additional page if needed.
1.
2.
3.
First and Last Name of Physician & Street Address
City
Zip Code
Phone Number
(
)
Name of Hospital Preference in case of emergency.
Yes
No
N/A
Complete the following information about medications for this child or youth.
Will this child or youth need to take any nonprescription or prescription medication during their time at the
program?
If yes above, is there signed permission on file?
CCL. 358
Kansas Department of Health and Environment
Rev. 3/2017
Bureau of Family Health
Child Care Licensing Program
1000 SW Jackson, Suite 200
Topeka, KS 66612-1274
Phone: (785) 296-1270 Fax (785) 559-4244
Website: www.kdheks.gov/kidsnet
HEALTH HISTORY FOR CHILDREN AND YOUTH ATTENDING SCHOOL AGE PROGRAMS
As required by K.A.R. 28-4-590(d) (1), each operator shall obtain a health history for each child or youth, on a form supplied by the
department or approved by the secretary. Each health history is to be maintained in the child’s or youth’s file on the premises. As
required by K.A.R. 28-4-590(d)(2), each operator shall require that each child or youth attending the program has current immunizations
as specified in K.A.R. 28-1-20 or has an exemption for religious or medical reasons.
Complete one form for each child or youth attending the School Age Program.
Gender
Date of Birth
First day at this program:
First and Last Name of the Child or Youth
(M or F)
(MM/DD/YYYY)
(MM/DD/YYYY)
First and Last Name of the Child’s or Youth’s Mother or Guardian
Mother/Guardian’s Home Street Address
City
Zip Code
Home Phone #
(
)
Mother/Guardian’s Work Place Name & Street Address
City
Zip Code
Work Phone #
(
)
First and Last Name of the Child’s or Youth’s Father or Guardian
Father/Guardian’s Home Street Address
City
Zip Code
Home Phone #
(
)
Father/Guardian’s Work Place Name & Street Address
City
Zip Code
Work Phone #
(
)
Names and ages of other children in the Child or Youth’s Family (Attach additional page if needed.)
Person(s) authorized to pick up the Child or Youth in
City
Zip Code
Phone Number (during
case of emergency. Include first and last name and
program hours):
Street Address. Attach additional page if needed.
1.
2.
3.
First and Last Name of Physician & Street Address
City
Zip Code
Phone Number
(
)
Name of Hospital Preference in case of emergency.
Yes
No
N/A
Complete the following information about medications for this child or youth.
Will this child or youth need to take any nonprescription or prescription medication during their time at the
program?
If yes above, is there signed permission on file?
Circle any of the following conditions or difficulties that affect this child or youth.
Allergies
Frequent sore throats/ colds
Ear Infections or Aches
Heart or Lung Conditions
Skin Problems
Asthma
Headaches
Diabetes
Vision
Speech/Communication
Hearing
Emotion/Behavior
Other: Please describe.
If you circled any of the above conditions, please provide additional information that will help the staff members meet the
child’s or youth’s needs while attending the program. (Attach additional page, if needed.)
Provide additional information about your child or youth that might affect him/her while at the School Age Program
including any special needs, restrictions to activities, major changes at home or special instructions. (Attach additional
page, if needed.
Complete the following information about this child’s or youth’s immunization status.
Yes
No
Did this child or youth attend a public or accredited non-public school in Kansas, Missouri or Oklahoma
the previous year?
If yes, are this child’s or youth’s immunizations current?
If yes to both of these questions, you do NOT need to complete the immunization history below.
If no to either of the above questions, you must complete the immunization history below for this child or
youth or attach a copy of the child’s or youth’s immunization history.
Please give dates in the space below for ALL immunization series completed by this child or youth. Record MM/DD/YYYY.
1
2
3
4
5
DPT, DT*, TD (*DT only if child is allergic to DTP)
/ /
/ /
/ /
/ /
/ /
POLIO
/ /
/ /
/ /
/ /
MMR
/ /
/ /
Single
RUBEOLA (MEASLES)
/ /
/ /
Dose
Only
MUMPS
/ /
/ /
RUBELLA (GERMAN MEASLES)
/ /
/ /
HIB (Hemophilus Influ. B)
*RECOMMENDED
/ /
/ /
/ /
/ /
HBV (Hepatitis B Vaccine)
*RECOMMENDED
/ /
/ /
/ /
VAR (Varicella-Chicken Pox) *RECOMMENDED
/ /
Print the First and Last Name of the Person Completing this Health History form
Relationship to the
Date Completed
Child/Youth
What is that person’s relationship to
If the Health History form was completed by a person other than a Parent/Guardian,
who provided you with this information?
the child/youth?
I attest, under penalty of perjury, that to the best of my knowledge, the information provided on this form is true and correct.
Signature of person completing this form
Date Signed
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