Form OCC1204 "Medical Report for Child Care" - Maryland

Form OCC1204 Printable Pdf
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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)
Maryland State Department of Education Maryland Legal Forms United States Legal Forms

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