Form CCL.029 "Medical Record for All Children in Child Care Facilities, Including Provider's Own Children" - Kansas

What Is Form CCL.029?

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, 2018;
  • 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.029 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.029 "Medical Record for All Children in Child Care Facilities, Including Provider's Own Children" - Kansas

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Kansas Department of Health and Environment
CCL. 029
Rev. 3/2018
Bureau of Family Health
Child Care Licensing Program
1000 SW Jackson, Suite 200
Topeka, KS 66612-1274
Phone (785) 296-1270 Fax (785) 559-4244
Website: www.kdheks.gov/kidsnet
MEDICAL RECORD FOR ALL CHILDREN IN CHILD CARE FACILITIES,
INCLUDING PROVIDER’S OWN CHILDREN
Parents are to complete the Medical Record and the History of Immunizations for each child in licensed child care
facilities. The Medical Record, History of Immunizations, and Child Health Assessment are transferable when the child
moves to another licensed child care facility.
Child’s First Day in Child Care
Name of Child Care Facility
Child’s Name
Date of Birth
__Gender
First
Last
MM/DD/YYYY
M/F
Parent/Guardian Information
Parent/Guardian Information
Name
Name
Home Address
Home Address
Street
City
Zip Code
Street
City
Zip Code
Home Phone Number
Home Phone Number
Work Address
Work Address
Street
City
Zip Code
Street
City
Zip Code
Work Phone Number
Work Phone Number
Cell Phone Number
Cell Phone Number
E-mail Address
E-mail Address
Best way to contact
Best way to contact
Names and ages of children in family
Persons authorized to pick up the child or to notify in case of emergency. Include name, address, and telephone number.
Attach an additional page, if necessary.
Child’s Physician
Phone Number
Child’s Dentist
Phone Number
Hospital Preference (for emergencies)
Has your physician approved the use of any non-prescription medications for your child such as acetaminophen, cough
syrup, or ointments that can be given by the child care provider?
No
Yes, as follows:
Does your child have any of the following conditions (yes or no)? If yes, provide information on Authorization for
Emergency Medical Care form CCL. 010.
Allergies
Frequent sore throats/colds
Ear Aches
Asthma
Speech, Visual, Hearing
Diabetes
Epilepsy/Seizures
Other
If yes answered to any above, please provide additional information
Have there been major changes at home that might affect your child in care?
No
Yes, as follows:
Please provide additional information or special instructions that will help the person caring for your child.
Parent/Guardian Signature: _________________________________________Date: _____________
1
Kansas Department of Health and Environment
CCL. 029
Rev. 3/2018
Bureau of Family Health
Child Care Licensing Program
1000 SW Jackson, Suite 200
Topeka, KS 66612-1274
Phone (785) 296-1270 Fax (785) 559-4244
Website: www.kdheks.gov/kidsnet
MEDICAL RECORD FOR ALL CHILDREN IN CHILD CARE FACILITIES,
INCLUDING PROVIDER’S OWN CHILDREN
Parents are to complete the Medical Record and the History of Immunizations for each child in licensed child care
facilities. The Medical Record, History of Immunizations, and Child Health Assessment are transferable when the child
moves to another licensed child care facility.
Child’s First Day in Child Care
Name of Child Care Facility
Child’s Name
Date of Birth
__Gender
First
Last
MM/DD/YYYY
M/F
Parent/Guardian Information
Parent/Guardian Information
Name
Name
Home Address
Home Address
Street
City
Zip Code
Street
City
Zip Code
Home Phone Number
Home Phone Number
Work Address
Work Address
Street
City
Zip Code
Street
City
Zip Code
Work Phone Number
Work Phone Number
Cell Phone Number
Cell Phone Number
E-mail Address
E-mail Address
Best way to contact
Best way to contact
Names and ages of children in family
Persons authorized to pick up the child or to notify in case of emergency. Include name, address, and telephone number.
Attach an additional page, if necessary.
Child’s Physician
Phone Number
Child’s Dentist
Phone Number
Hospital Preference (for emergencies)
Has your physician approved the use of any non-prescription medications for your child such as acetaminophen, cough
syrup, or ointments that can be given by the child care provider?
No
Yes, as follows:
Does your child have any of the following conditions (yes or no)? If yes, provide information on Authorization for
Emergency Medical Care form CCL. 010.
Allergies
Frequent sore throats/colds
Ear Aches
Asthma
Speech, Visual, Hearing
Diabetes
Epilepsy/Seizures
Other
If yes answered to any above, please provide additional information
Have there been major changes at home that might affect your child in care?
No
Yes, as follows:
Please provide additional information or special instructions that will help the person caring for your child.
Parent/Guardian Signature: _________________________________________Date: _____________
1
History of Immunizations
Required for all children in child care facilities, including the provider’s own children. A Kansas Certificate of
Immunizations (KCI) may be substituted for this form and attached to the completed Medical Record.
Child’s Name:
Date of Birth:
First
Last
MM/DD/YYYY
Section I. For a recommended schedule of immunizations, refer to the current schedule published by the
Advisory Committee on Immunization Practices (ACIP).
Vaccine
Record the Month. Day and Year that each Dose of Vaccine was Received
1
st
2
nd
3
rd
4
th
5
th
6
th
Diphtheria, Tetanus, Pertussis
(DTaP)
Poliomyelitis (IPV/OPV)
Measles, Mumps, Rubella (MMR)
Hepatitis B (HepB)
Hx of Disease:
Date of Illness:
Varicella (VAR)
Physician Signature
Hemophilus Influenzae Type B (Hib)
Pneumococcal Conjugate (PCV)
Hepatitis A (HepA)
Rotavirus **Recommended <8 mo of
age; not required
Influenza(Flu) ** Recommended
annually >6 mo of age; not required
Section II.
Complete this section only if your child is exempted from the law requiring immunizations [K.S.A. 65-508(d)].
Section II. Complete Section below only if your child is exempted from laws requiring requiring
The following two options are the ONLY exemptions allowed by law. Please check either (A) or (B) below and
immunizations [ K.S.A. 65-508(d) and K.S.A. 65-519(c) ]
complete as required:
 (A) Certification from licensed physician stating that immunization would endanger child’s life:
Exempt from following immunizations:
DTaP/DT _____Tdap/TD
Pertussis Only ____Polio
MMR
HepA
HepB
Hib
_____PCV ____Varicella ___Other
Physician’s Signature (required): ________________________________________________Date:_______________
 (B) My child is exempt under the law from immunizations. As the Parent or Legal Guardian, I state
that I am an adherent of a religious denomination whose teachings are opposed to immunizations.
Section III.
Parent/Guardian Signature: ________________________________________Date:________________
2
CCL. 029a
Rev. 3/2017
Child Health Assessment
The Child Health Assessment form is to be completed and signed by a nurse approved by KDHE to perform Child Health
Assessments or a Licensed Physician. If a Physician Assistant (PA) completes the Child Health Assessment, the signature
of the Licensed Physician authorizing the PA is to be included at the bottom of this form.
A Child Health Assessment, recorded on a KDHE Form or other acceptable Forms mentioned below, is required for all
children including children of the provider or staff in Licensed Day Care Homes, Group Day Care Homes, Child Care
Centers and Preschools. A Kan-Be-Healthy Assessment Form is a KDHE Form and is acceptable, a Physician Health
Assessment Form is acceptable, and a School Health Assessment Form is acceptable for school-age children or youth.
The Health Assessment Form used should be attached to the KDHE Medical Record Form (CCL. 029).
Child’s Name_________________________________________
Date of Birth___________________
First
Last
Health history and medical information pertinent to routine child care and emergencies
Do you see this child for regular
(describe, if any):
health supervision:
 None
Yes
 No
Allergies to food or medicine (describe, if any):
 None
List current medications (if any):
 None
Length/Height: ______IN/CM
%ILE_______
Weight: _____LB/KG
%ILE_______
Physical Examination
If Normal
If Abnormal - Comments
Head/Ears/Eyes/Nose/Throat
Teeth
Cardio/Respiratory
Abdomen/GI
Genitalia/Breasts
Extremities/Joints/Back/Chest
Skin/Lymph Nodes
Neurologic & Developmental
Screening Tests
Screening Date
Note Here if Results are Pending or Abnormal
Lead
Anemia (HGB/HCT)
Urinalysis (UA)
Hearing
Vision
Health Problems or Special Needs, Recommended Treatment/Medications/Special Care (Attach additional sheets if necessary)
 None
Signature of Licensed Physician or Nurse approved for Child Health Assessments
Date
Print the Name of the Individual Signing Above
Phone Number
Address
City
Zip Code
3
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