Form OCC1204 "Medical Report for Child Care" - Maryland

What Is Form OCC1204?

This is a legal form that was released by the Maryland State Department of Education - a government authority operating within Maryland. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on March 1, 2019;
  • The latest edition provided by the Maryland State Department of Education;
  • 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 OCC1204 by clicking the link below or browse more documents and templates provided by the Maryland State Department of Education.

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Download Form OCC1204 "Medical Report for Child Care" - Maryland

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MARYLAND STATE DEPARTMENT OF EDUCATION
Office of Child Care
MEDICAL REPORT FOR CHILD CARE
A.Name of the Person Evaluated (Please Print):
D. Reason for Examination:
⎕Initial Employment
⎕ Biennial
B. Date of Birth:
Age:
⎕ Other
C.Name and Address of Child Care Applicant/Provider/Facility:
(Two Year Update)
E. PLEASE READ: This person to be evaluated either provides or plans to provide child care services, lives in a home where child care is
provided or will be provided. The Medical Evaluation is to assess this individual’s ability to perform the following Child Care Activities:
Lifting, carrying children (infants, toddlers, preschool and school age)
Desk work, reading & writing
Lifting/moving children furniture/equipment
Active indoor and outdoor activities
Getting up and down from floor
Facility maintenance
Close interaction with children
Driver of Vehicle (s)
Food preparation, serving, feeding and holding young infants
Other duties associated with assisting children in need, etc.
F. This Section Must Be Completed by a Physician or Registered Physician Assistant or Certified Registered Nurse Practitioner
Yes
No
Remarks
1.Did you conduct a medical evaluation?
a.
Chronic medical conditions which may limit the ability
to care for children, such as Epilepsy, asthma, others
Impairment (Mobility/ Vision/ Hearing/ Speech )
Nervous / Emotional/ Mental health disorder
Drug /Alcohol Abuse
Smoking
Tuberculosis Screening:
symptoms check
screening: if needed or required by the Local Health
Officer:
Type of test:
_
Date (s):
_
Communicable/Contagious diseases risk
Immunization status
2. Medical condition(s) or medication (s) the person is taking that
may restrict /prevent the person’s ability to perform care activities
3. Medical limitation(s) or medication(s) the person is taking, that
may require special accommodation: Please specify:
4. Based on your findings, is this individual suitable/able to provide
safe care to the children in child care or live in a child care home
Additional Remarks:
G. Signature of the Health Care Provider:
Date:
Printed Name & Credentials:
STAMP OR Complete Address of the Health Care Provider & Telephone Number:
OCC 1204 - Revised 3/19 (All previous editions obsolete and replaces OCC 1204 6/08, 6/18 & OCC 1258)
MARYLAND STATE DEPARTMENT OF EDUCATION
Office of Child Care
MEDICAL REPORT FOR CHILD CARE
A.Name of the Person Evaluated (Please Print):
D. Reason for Examination:
⎕Initial Employment
⎕ Biennial
B. Date of Birth:
Age:
⎕ Other
C.Name and Address of Child Care Applicant/Provider/Facility:
(Two Year Update)
E. PLEASE READ: This person to be evaluated either provides or plans to provide child care services, lives in a home where child care is
provided or will be provided. The Medical Evaluation is to assess this individual’s ability to perform the following Child Care Activities:
Lifting, carrying children (infants, toddlers, preschool and school age)
Desk work, reading & writing
Lifting/moving children furniture/equipment
Active indoor and outdoor activities
Getting up and down from floor
Facility maintenance
Close interaction with children
Driver of Vehicle (s)
Food preparation, serving, feeding and holding young infants
Other duties associated with assisting children in need, etc.
F. This Section Must Be Completed by a Physician or Registered Physician Assistant or Certified Registered Nurse Practitioner
Yes
No
Remarks
1.Did you conduct a medical evaluation?
a.
Chronic medical conditions which may limit the ability
to care for children, such as Epilepsy, asthma, others
Impairment (Mobility/ Vision/ Hearing/ Speech )
Nervous / Emotional/ Mental health disorder
Drug /Alcohol Abuse
Smoking
Tuberculosis Screening:
symptoms check
screening: if needed or required by the Local Health
Officer:
Type of test:
_
Date (s):
_
Communicable/Contagious diseases risk
Immunization status
2. Medical condition(s) or medication (s) the person is taking that
may restrict /prevent the person’s ability to perform care activities
3. Medical limitation(s) or medication(s) the person is taking, that
may require special accommodation: Please specify:
4. Based on your findings, is this individual suitable/able to provide
safe care to the children in child care or live in a child care home
Additional Remarks:
G. Signature of the Health Care Provider:
Date:
Printed Name & Credentials:
STAMP OR Complete Address of the Health Care Provider & Telephone Number:
OCC 1204 - Revised 3/19 (All previous editions obsolete and replaces OCC 1204 6/08, 6/18 & OCC 1258)