Form MO580-1879 "Medical Examination Report for Caregivers and Staff" - Missouri

What Is Form MO580-1879?

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

Form Details:

  • Released on June 1, 2014;
  • The latest edition provided by the Missouri Department of Health and Senior Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form MO580-1879 by clicking the link below or browse more documents and templates provided by the Missouri Department of Health and Senior Services.

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Download Form MO580-1879 "Medical Examination Report for Caregivers and Staff" - Missouri

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missouri department of health and senior services
SAVE
section for child care regulation
MEDICAL EXAMINATION REPORT FOR CAREGIVERS AND STAFF
PRINT
RESET
patient may:
have contact with children (infant through school-age) in care away from their own homes.
be responsible for children’s physical care and social development during day and/or nighttime hours.
need to lift children.
IDENTIFYING INFORMATION (To be completed by patient.)
name
birthdate
address (street, city, state, zip code)
telephone number
(
)
name and address of child care facility where employed
MEDICAL REPORT (To be completed by a licensed physician or advance practice nurse; by registered professional nurse or
registered nurse who is under the supervision of a licensed physician.)
on _______________________ (date), i examined this patient. i certify that to the best of my knowledge, this patient
PHYSICAL
EXAMINATION
is in good physical and emotional health and free of contagious disease.
yes     
no
(check one.)
tb risk assessment form attached (required)
TB CLEARANCE
a chest x-ray or appropriate written follow-up of a previous examination that indicates the individual is free of
contagion dated _____________________________________ .
the above dated physical examination indicates this patient has the following physical or mental conditions that might
endanger the health of children or might prevent the patient from providing adequate care of children:
LIMITATIONS
none
_______________________________________________________________________________________
this patient has the following restrictions, e.g., cannot lift children who weigh more than 20 pounds, etc.
RESTRICTIONS
none
_______________________________________________________________________________________
REMARKS
SIGNATURES
signature of physician or registered nurse under
date
physician’s or nurse’s name (please print.)
supervision of a physician
name and address of clinic, group practice, other
if nurse is supervised by physician, indicate physician’s name.
(please use stamp, if available)
(please print.)
telephone number
(
)
this form is to be kept on file at the child care facility
mO 580-1879 (6-14)
BCC-4
missouri department of health and senior services
SAVE
section for child care regulation
MEDICAL EXAMINATION REPORT FOR CAREGIVERS AND STAFF
PRINT
RESET
patient may:
have contact with children (infant through school-age) in care away from their own homes.
be responsible for children’s physical care and social development during day and/or nighttime hours.
need to lift children.
IDENTIFYING INFORMATION (To be completed by patient.)
name
birthdate
address (street, city, state, zip code)
telephone number
(
)
name and address of child care facility where employed
MEDICAL REPORT (To be completed by a licensed physician or advance practice nurse; by registered professional nurse or
registered nurse who is under the supervision of a licensed physician.)
on _______________________ (date), i examined this patient. i certify that to the best of my knowledge, this patient
PHYSICAL
EXAMINATION
is in good physical and emotional health and free of contagious disease.
yes     
no
(check one.)
tb risk assessment form attached (required)
TB CLEARANCE
a chest x-ray or appropriate written follow-up of a previous examination that indicates the individual is free of
contagion dated _____________________________________ .
the above dated physical examination indicates this patient has the following physical or mental conditions that might
endanger the health of children or might prevent the patient from providing adequate care of children:
LIMITATIONS
none
_______________________________________________________________________________________
this patient has the following restrictions, e.g., cannot lift children who weigh more than 20 pounds, etc.
RESTRICTIONS
none
_______________________________________________________________________________________
REMARKS
SIGNATURES
signature of physician or registered nurse under
date
physician’s or nurse’s name (please print.)
supervision of a physician
name and address of clinic, group practice, other
if nurse is supervised by physician, indicate physician’s name.
(please use stamp, if available)
(please print.)
telephone number
(
)
this form is to be kept on file at the child care facility
mO 580-1879 (6-14)
BCC-4