"Adult Health Appraisal for Child Care" - Delaware

This "Adult Health Appraisal for Child Care" is a document issued by the Delaware Department of Services for Children, Youth and their Families specifically for Delaware residents with its latest version released on May 1, 2017.

Download the up-to-date fillable PDF by clicking the link below or find it on the forms website of the Delaware Department of Services for Children, Youth and their Families.

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Download "Adult Health Appraisal for Child Care" - Delaware

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ADULT HEALTH APPRAISAL FOR CHILD CARE
PRINT NAME _________________________________________ DATE OF BIRTH __________________
DATE OF HEALTH EXAMINATION__________________________________________________________
Type of Activity in Child Care (check all applicable):
[ ] Caring for Children
[ ] Adult Member of Household
[ ] Food Preparation
[ ] Driver of Vehicle
[ ] Desk Work
[ ] Facility Maintenance
[ ] Other __________________________________________________________
THIS SECTION IS TO BE COMPLETED BY HEALTH PROFESSIONAL WHO DOES HEALTH APPRAISAL
1. As shown by your physical examination, is this individual physically and emotionally healthy and
Yes
No
able to perform the tasks needed to provide adequate care for children?
If no, please explain:
2. Does this individual have any special medical problems that might interfere with the health of
Yes
No
children or might prohibit the individual from providing adequate care for children?
If yes, please explain:
3. Is this individual free from communicable diseases?
Yes
No
If no, please explain:
4. This individual has had a tuberculosis (TB) determination conducted within the past 12 months by (check one):
A negative skin test or TB risk assessment ☐Yes ☐ No
OR
A positive skin test followed by one negative x-ray and an asymptomatic history at this health appraisal.
☐Yes ☐ No ��
IF BOTH ARE "NO" RESPONSES, PLEASE EXPLAIN AND PROVIDE PLAN FOR FOLLOW-UP:
PRINT Name of Health Care Professional Licensed to Perform Health Appraisals
Telephone Number
__________________________________________________________________________________________________________
PRINT Address of Health Care Professional Licensed to Perform Health Appraisals
Signature of Health Care Professional Licensed to Perform Health Appraisals
Date
Revised May 2017
ADULT HEALTH APPRAISAL FOR CHILD CARE
PRINT NAME _________________________________________ DATE OF BIRTH __________________
DATE OF HEALTH EXAMINATION__________________________________________________________
Type of Activity in Child Care (check all applicable):
[ ] Caring for Children
[ ] Adult Member of Household
[ ] Food Preparation
[ ] Driver of Vehicle
[ ] Desk Work
[ ] Facility Maintenance
[ ] Other __________________________________________________________
THIS SECTION IS TO BE COMPLETED BY HEALTH PROFESSIONAL WHO DOES HEALTH APPRAISAL
1. As shown by your physical examination, is this individual physically and emotionally healthy and
Yes
No
able to perform the tasks needed to provide adequate care for children?
If no, please explain:
2. Does this individual have any special medical problems that might interfere with the health of
Yes
No
children or might prohibit the individual from providing adequate care for children?
If yes, please explain:
3. Is this individual free from communicable diseases?
Yes
No
If no, please explain:
4. This individual has had a tuberculosis (TB) determination conducted within the past 12 months by (check one):
A negative skin test or TB risk assessment ☐Yes ☐ No
OR
A positive skin test followed by one negative x-ray and an asymptomatic history at this health appraisal.
☐Yes ☐ No ��
IF BOTH ARE "NO" RESPONSES, PLEASE EXPLAIN AND PROVIDE PLAN FOR FOLLOW-UP:
PRINT Name of Health Care Professional Licensed to Perform Health Appraisals
Telephone Number
__________________________________________________________________________________________________________
PRINT Address of Health Care Professional Licensed to Perform Health Appraisals
Signature of Health Care Professional Licensed to Perform Health Appraisals
Date
Revised May 2017
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