Form CCL.357 "Health Status Form for Persons 14 Years of Age or Older Working or Volunteering in School Age Programs" - Kansas

What Is Form CCL.357?

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;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form CCL.357 by clicking the link below or browse more documents and templates provided by the Kansas Department of Health & Environment.

ADVERTISEMENT
ADVERTISEMENT

Download Form CCL.357 "Health Status Form for Persons 14 Years of Age or Older Working or Volunteering in School Age Programs" - Kansas

720 times
Rate (4.8 / 5) 50 votes
Kansas Department of Health and Environment
CCL.357
Rev. 3/2017
Bureau of Family Health
1000 SW Jackson, Suite 200
Topeka, KS 66612-1274
Phone:785-296-1270 Fax:785-559-4244
Website: www.kdheks.gov/kidsnet
HEALTH STATUS FORM FOR PERSONS 14 YEARS OF AGE OR OLDER
WORKING OR VOLUNTEERING IN SCHOOL AGE PROGRAMS
As required by K. A. R. 28-4-590(b)(4), each operator and each staff member who has regular, ongoing contact with children or youth shall
attest to that individual’s health status on a form supplied by the department or approved by the secretary. The health status form shall indicate
if the individual has been exposed to an active case of tuberculosis or has been diagnosed with suspect or confirmed active tuberculosis. Each
individual shall update the health status form annually or more often if there is a change in the health status or if the individual has been
exposed to an active case of tuberculosis.
PLEASE PRINT.
Name of the School Age Program exactly as stated on the license.
License Number
Facility Street Address:
City
Zip Code + 4
County
First and Last Name of the Individual for which this Health Status applies:
Date of Birth (MM/DD/YYYY)
In case of emergency, program staff should contact the following person.
Relationship to you.
Their Phone Number
First and Last Name:
(
)
Please check each question. If answer is yes, please explain.
Yes
No
1.
Do you see a health care provider regularly for any health condition?
___
___
2.
Have you had any surgery in the past 3 years?
___
___
3.
Do you have any health conditions which might interfere with your care of children or youth?
___
___
4
Do you take any medications which might interfere with your care of children or youth?
___
___
5.
Do you have any chronic illness conditions that might interfere with your care of children or youth such as:
Yes
No
Yes
No
Yes
No
Headaches
___
___
Cancer
___
___
Alcoholism
___
___
Heart Disease
___
___
Diabetes
___
___
Arthritis
___
___
High Blood Pressure
___
___
Convulsions
___
___
Liver Disease
___
___
Lung Disease
___
___
Mental Illness
___
___
Other
___
___
If you answer yes to any of the above, please explain further. Attach an additional page if needed.
OVER - COMPLETE BOTH SIDES OF FORM
Kansas Department of Health and Environment
CCL.357
Rev. 3/2017
Bureau of Family Health
1000 SW Jackson, Suite 200
Topeka, KS 66612-1274
Phone:785-296-1270 Fax:785-559-4244
Website: www.kdheks.gov/kidsnet
HEALTH STATUS FORM FOR PERSONS 14 YEARS OF AGE OR OLDER
WORKING OR VOLUNTEERING IN SCHOOL AGE PROGRAMS
As required by K. A. R. 28-4-590(b)(4), each operator and each staff member who has regular, ongoing contact with children or youth shall
attest to that individual’s health status on a form supplied by the department or approved by the secretary. The health status form shall indicate
if the individual has been exposed to an active case of tuberculosis or has been diagnosed with suspect or confirmed active tuberculosis. Each
individual shall update the health status form annually or more often if there is a change in the health status or if the individual has been
exposed to an active case of tuberculosis.
PLEASE PRINT.
Name of the School Age Program exactly as stated on the license.
License Number
Facility Street Address:
City
Zip Code + 4
County
First and Last Name of the Individual for which this Health Status applies:
Date of Birth (MM/DD/YYYY)
In case of emergency, program staff should contact the following person.
Relationship to you.
Their Phone Number
First and Last Name:
(
)
Please check each question. If answer is yes, please explain.
Yes
No
1.
Do you see a health care provider regularly for any health condition?
___
___
2.
Have you had any surgery in the past 3 years?
___
___
3.
Do you have any health conditions which might interfere with your care of children or youth?
___
___
4
Do you take any medications which might interfere with your care of children or youth?
___
___
5.
Do you have any chronic illness conditions that might interfere with your care of children or youth such as:
Yes
No
Yes
No
Yes
No
Headaches
___
___
Cancer
___
___
Alcoholism
___
___
Heart Disease
___
___
Diabetes
___
___
Arthritis
___
___
High Blood Pressure
___
___
Convulsions
___
___
Liver Disease
___
___
Lung Disease
___
___
Mental Illness
___
___
Other
___
___
If you answer yes to any of the above, please explain further. Attach an additional page if needed.
OVER - COMPLETE BOTH SIDES OF FORM
Please check each of the following statements:
_____Yes _____No
I am free from physical, mental, or emotional handicaps as necessary to protect the health, safety, and
welfare of the children or youth as required by K.A.R. 28-4-590(b)(1).
_____Yes _____No
When I am working or volunteering in the School Age Program, I will not be under the influence of alcohol
or illegal substances or impaired due to the use of prescription or nonprescription drugs as required by
K.A.R. 28-4-290(b)(2).
_____Yes _____No
I am free from any infectious or contagious disease as specified in K.A.R. 28-1-6 (see below) as required by
K.A.R. 28-4-590(b)(3).
_____Yes _____No
I have not been exposed to active tuberculosis.
_____Yes _____No
I have not been diagnosed with suspect or confirmed active tuberculosis.
I attest, under penalty of perjury, that to the best of my knowledge, the information provided on this Health Status Form
is true and correct.
Signature
Date Signed (MM/DD/YYYY)
ANNUAL UPDATE
Signature _____________________________________________________________________
Date Updated____________________
Signature _____________________________________________________________________
Date Updated____________________
Signature _____________________________________________________________________
Date Updated____________________
Signature _____________________________________________________________________
Date Updated____________________
K.A.R. 28-1-6
(a)
Amebiases;
(b)
Anthrax;
(c)
Chickenpox;
(d)
Cholera;
(e)
Diphtheria;
(f)
E. coli 0157:H7;
(g)
Gonorrhea;
(h)
Malaria;
(i)
Meningitis, meningococcal;
(j)
Meningitis, aseptic and other;
(k)
Mumps;
(l)
Pediculosis;
(m)
Pertusis;
(n)
Plague;
(o)
Poliomyelitis;
(p)
Rubeola;
(q)
Rubella;
(r)
Salmonellosis (nontyphoidal);
(s)
Scabies;
(t)
Shigellosis;
(u)
Staphylococcal disease;
(v)
Streptococcal disease, hemolytic;
(w)
Taeniasis (beef or pork tapeworm);
(x)
Tinea capitis and corporis (ringworm);
(y)
Tuberculosis;
(z)
Typhoid fever;
(aa)
Sexually transmitted diseases;
(bb)
Viral hepatitis type A;
OVER - COMPLETE BOTH SIDES OF FORM
Page of 2