Form CCL.009 "Certificate of Health Assessment" - Kansas

This version of the form is not currently in use and is provided for reference only.
Download this version of Form CCL.009 for the current year.

What Is Form CCL.009?

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;
  • Available in Spanish;
  • 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.009 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.009 "Certificate of Health Assessment" - Kansas

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Kansas Department of Health and Environment
CCL. 009
Rev. 3/2017
Bureau of Family Health
1000 SW Jackson, Suite 200
Topeka, KS 66612-1274
Child Care Program:
(785) 296 -1270 Fax: (785) 559-4244
Website: www.kdheks.gov/kidsnet
CERTIFICATE OF HEALTH ASSESSMENT
K.A.R. 28-4-126(b)(1) requires each person regularly caring for children to have a health assessment completed by a licensed physician or by a
nurse trained to perform health assessments.
Substitutes in a licensed day care home or licensed group day care home are not required to obtain a health assessment. A Physician’s Assistant
(PA) may complete the health assessment. The health assessment must be recorded on the KDHE form.
 Licensed or Group Day Care Home
 Child Care Center/Preschool/Head Start
CHILD CARE FACILITY:
______________________________________________________________________
____________________________
Name of the facility (exactly as stated on the license)
License #
__________________________________________________________________________________________________________
Street Address
City
Zip Code
County
TO BE COMPLETED BY PROVIDER/STAFF (Please print and answer all questions in this section):
Name of Provider/Staff _______________________________________________________ Date of Birth ______________________
(First)
(Middle)
(Last)
(MM/DD/YYYY)
Check below any chronic illness(es) or list any medications that may interfere with child care duties:
Debilitating Headaches/Migraines
Cancer
Active Substance Abuse
Heart Disease
Hearing or Vision
Diabetes
Arthritis
High Blood Pressure
Convulsions
Liver Disease
Lung Disease
Mental Illness
Use of any durable medical equipment (walker, cane, oxygen, etc.), describe: ___________________________________________
List any other medical condition that would interfere with child care duties: ______________________________________________
List any medications that would interfere with child care duties: ______________________________________________________
CHILD CARE DAY DUTIES MAY INCLUDE*:
 Lifting and carrying children
 Stooping/bending
 Use of stairs (up and down)
 Close contact with children
 Facility maintenance
 Recordkeeping
 Driver of vehicle
 Food preparation
 Evacuation of children in an emergency
 Ability to supervise and engage in child care activities
I certify that this information contains no willful misrepresentation or falsification and that it is true and complete to the best of my
knowledge and belief. I hereby authorize the Kansas Department of Health and Environment to contact the persons listed on this
form. I understand that the Department may contact others, seek verification of any and all information on this form. I understand
that any willful misrepresentation is cause for immediate denial of the application or later revocation of the license.
Provider/Staff Signature ______________________________________________
Date: _______________________
TO BE COMPLETED BY A PERSON AUTHORIZED TO PERFORM HEALTH ASSESSMENTS:
I have reviewed the above information, conducted an
I have reviewed the above information, conducted an
examination and any required tests. The above patient:
examination and any required tests. The above patient:
 Does not have evidence of a medical condition or mental
Does have evidence of a medical condition or mental illness
illness that would interfere with typical child care duties listed
that would interfere with typical child care duties listed above.*
above.*
________________________________________________________
________________________________________________________
Authorizing Signature
Date
Authorized Signature
Date
Name of office/clinic (Please Print): ______________________________________________________________________________
____________________________________________________________________________________________________________________________________________
Street Address
City
Zip Code
Telephone Number
RECORD RESULTS OF TB TEST OR ATTACH RESULTS TO THIS FORM:
Negative tuberculin test ____ or negative chest x-ray ____ on ___________________________ (date). (Repeat test not needed
unless there is exposure or symptoms.)
Test read by ___________________________________________________________________
___________________________
Licensed Physician/Nurse Signature or Health Department
Date (MM/DD/YYYY)
Kansas Department of Health and Environment
CCL. 009
Rev. 3/2017
Bureau of Family Health
1000 SW Jackson, Suite 200
Topeka, KS 66612-1274
Child Care Program:
(785) 296 -1270 Fax: (785) 559-4244
Website: www.kdheks.gov/kidsnet
CERTIFICATE OF HEALTH ASSESSMENT
K.A.R. 28-4-126(b)(1) requires each person regularly caring for children to have a health assessment completed by a licensed physician or by a
nurse trained to perform health assessments.
Substitutes in a licensed day care home or licensed group day care home are not required to obtain a health assessment. A Physician’s Assistant
(PA) may complete the health assessment. The health assessment must be recorded on the KDHE form.
 Licensed or Group Day Care Home
 Child Care Center/Preschool/Head Start
CHILD CARE FACILITY:
______________________________________________________________________
____________________________
Name of the facility (exactly as stated on the license)
License #
__________________________________________________________________________________________________________
Street Address
City
Zip Code
County
TO BE COMPLETED BY PROVIDER/STAFF (Please print and answer all questions in this section):
Name of Provider/Staff _______________________________________________________ Date of Birth ______________________
(First)
(Middle)
(Last)
(MM/DD/YYYY)
Check below any chronic illness(es) or list any medications that may interfere with child care duties:
Debilitating Headaches/Migraines
Cancer
Active Substance Abuse
Heart Disease
Hearing or Vision
Diabetes
Arthritis
High Blood Pressure
Convulsions
Liver Disease
Lung Disease
Mental Illness
Use of any durable medical equipment (walker, cane, oxygen, etc.), describe: ___________________________________________
List any other medical condition that would interfere with child care duties: ______________________________________________
List any medications that would interfere with child care duties: ______________________________________________________
CHILD CARE DAY DUTIES MAY INCLUDE*:
 Lifting and carrying children
 Stooping/bending
 Use of stairs (up and down)
 Close contact with children
 Facility maintenance
 Recordkeeping
 Driver of vehicle
 Food preparation
 Evacuation of children in an emergency
 Ability to supervise and engage in child care activities
I certify that this information contains no willful misrepresentation or falsification and that it is true and complete to the best of my
knowledge and belief. I hereby authorize the Kansas Department of Health and Environment to contact the persons listed on this
form. I understand that the Department may contact others, seek verification of any and all information on this form. I understand
that any willful misrepresentation is cause for immediate denial of the application or later revocation of the license.
Provider/Staff Signature ______________________________________________
Date: _______________________
TO BE COMPLETED BY A PERSON AUTHORIZED TO PERFORM HEALTH ASSESSMENTS:
I have reviewed the above information, conducted an
I have reviewed the above information, conducted an
examination and any required tests. The above patient:
examination and any required tests. The above patient:
 Does not have evidence of a medical condition or mental
Does have evidence of a medical condition or mental illness
illness that would interfere with typical child care duties listed
that would interfere with typical child care duties listed above.*
above.*
________________________________________________________
________________________________________________________
Authorizing Signature
Date
Authorized Signature
Date
Name of office/clinic (Please Print): ______________________________________________________________________________
____________________________________________________________________________________________________________________________________________
Street Address
City
Zip Code
Telephone Number
RECORD RESULTS OF TB TEST OR ATTACH RESULTS TO THIS FORM:
Negative tuberculin test ____ or negative chest x-ray ____ on ___________________________ (date). (Repeat test not needed
unless there is exposure or symptoms.)
Test read by ___________________________________________________________________
___________________________
Licensed Physician/Nurse Signature or Health Department
Date (MM/DD/YYYY)