Form CFS602 "Medical Report on an Adult in a Child Care Facility" - Illinois

What Is Form CFS602?

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

Form Details:

  • Released on March 1, 2016;
  • The latest edition provided by the Illinois Department of Children and Family 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 CFS602 by clicking the link below or browse more documents and templates provided by the Illinois Department of Children and Family Services.

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Download Form CFS602 "Medical Report on an Adult in a Child Care Facility" - Illinois

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CFS 602
STATE OF ILLINOIS
Rev. 03/2016
Department of Children and Family Services
MEDICAL REPORT ON AN ADULT IN A CHILD CARE FACILITY
(Includes employees and volunteers in DCFS licensed child care facilities, operators
of day care/group day care homes and other adult members of their households)
(Name of Person Examined)
(Birth Date)
Position (check one)
Day Care/Group Day Care Home Caregiver
Food Handler (See Section B)
Child Care Staff
Child Care Facility Driver (See Section B)
Other Staff in a Child Care Facility
Volunteer in a Child Care Facility
Member of Household
Name of Licensee/applicant for License or Licensed
Facility where individual is employed/volunteers
Address
Street
City
Zip Code
County
I.
TESTS
Date
Results
Tuberculin test (by the Mantoux method or chest X-ray
in a positive reactor)*
Other (specify):
II. IMMUNIZATIONS
Yes
No I have discussed the importance of immunizations for adult child care providers with this individual and
recommend the following immunizations:
If this individual is employed in a child care facility that cares for children age 6 and under, please check two of the following:
This individual has received:
1 dose of the Tdap vaccine
2 doses of the MMR vaccine or is immune to MMR.
This individual is not medically indicated for:
1 dose of the Tdap vaccine
2 doses of the MMR vaccinations.
III. FINDINGS AND RECOMMENDATIONS
A. Findings
Summary of medical or emotional problems or conditions, if any, which may affect the individual’s ability to work, volunteer
or reside in a facility caring for children.
B. Any conditions which contraindicate a person serving as a Food Handler or Child Care Facility Driver?
Yes
No If yes, please specify
C. Recommendations
The above individual was found free from symptoms of communicable disease and is otherwise medically and emotionally
fit to work, volunteer or reside in a facility caring for children.
Yes
No
Explain “No”:
In my opinion, the individual could meet the strength and mobility challenges required for caring for a child in one or more
of the age groups checked below:
0-2 years of age
2-6 years of age
7-12 years of age
12-18 years of age
Date of Examination
Physician’s Name (Print) and State License Number
Physician’s Signature
Street Address
City
State
Zip Code
Telephone Number
* Required in initial examination only. Physician to determine need for test in subsequent examinations.
CFS 602
STATE OF ILLINOIS
Rev. 03/2016
Department of Children and Family Services
MEDICAL REPORT ON AN ADULT IN A CHILD CARE FACILITY
(Includes employees and volunteers in DCFS licensed child care facilities, operators
of day care/group day care homes and other adult members of their households)
(Name of Person Examined)
(Birth Date)
Position (check one)
Day Care/Group Day Care Home Caregiver
Food Handler (See Section B)
Child Care Staff
Child Care Facility Driver (See Section B)
Other Staff in a Child Care Facility
Volunteer in a Child Care Facility
Member of Household
Name of Licensee/applicant for License or Licensed
Facility where individual is employed/volunteers
Address
Street
City
Zip Code
County
I.
TESTS
Date
Results
Tuberculin test (by the Mantoux method or chest X-ray
in a positive reactor)*
Other (specify):
II. IMMUNIZATIONS
Yes
No I have discussed the importance of immunizations for adult child care providers with this individual and
recommend the following immunizations:
If this individual is employed in a child care facility that cares for children age 6 and under, please check two of the following:
This individual has received:
1 dose of the Tdap vaccine
2 doses of the MMR vaccine or is immune to MMR.
This individual is not medically indicated for:
1 dose of the Tdap vaccine
2 doses of the MMR vaccinations.
III. FINDINGS AND RECOMMENDATIONS
A. Findings
Summary of medical or emotional problems or conditions, if any, which may affect the individual’s ability to work, volunteer
or reside in a facility caring for children.
B. Any conditions which contraindicate a person serving as a Food Handler or Child Care Facility Driver?
Yes
No If yes, please specify
C. Recommendations
The above individual was found free from symptoms of communicable disease and is otherwise medically and emotionally
fit to work, volunteer or reside in a facility caring for children.
Yes
No
Explain “No”:
In my opinion, the individual could meet the strength and mobility challenges required for caring for a child in one or more
of the age groups checked below:
0-2 years of age
2-6 years of age
7-12 years of age
12-18 years of age
Date of Examination
Physician’s Name (Print) and State License Number
Physician’s Signature
Street Address
City
State
Zip Code
Telephone Number
* Required in initial examination only. Physician to determine need for test in subsequent examinations.
REEXAMINATIONS
Date of Examination
Physician’s Name (Print) and State License Number
Date of Examination
Physician’s Name (Print) and State License Number
Date of Examination
Physician’s Name (Print) and State License Number
Date of Examination
Physician’s Name (Print) and State License Number
Date of Examination
Physician’s Name (Print) and State License Number
Date of Examination
Physician’s Name (Print) and State License Number
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