Form DCF-F-CFS0384 "Staff Health Report - Child Welfare Facilities" - Wisconsin

What Is Form DCF-F-CFS0384?

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

Form Details:

  • Released on April 1, 2010;
  • The latest edition provided by the Wisconsin Department of Children and Families;
  • 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 DCF-F-CFS0384 by clicking the link below or browse more documents and templates provided by the Wisconsin Department of Children and Families.

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Download Form DCF-F-CFS0384 "Staff Health Report - Child Welfare Facilities" - Wisconsin

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DEPARTMENT OF CHILDREN AND FAMILIES
Division of Safety and Permanence
DCF-F-CFS0384 (R. 04/2010)
STAFF HEALTH REPORT – CHILD WELFARE FACILITIES
Use of form: Use of this form is voluntary. However, completion of this form by a physician, physician’s assistant or HealthCheck provider
meets the requirements of DCF 52.12(3)(e), 57.15(2)(c) and 59.04(1)(b)3. This form or its equivalent must be completed and on file prior to
staff working with residents. Personally identifiable information gathered on this form will be used only to verify compliance with licensing
rules. Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04(1)(m), Wisconsin Statutes].
Instructions: Each staff person shall present this form or its equivalent to the physician, physician’s assistant or HealthCheck provider to be
filled out and signed upon completion of the required health examination. The child welfare facility shall file the completed health report in the
staff person’s personnel record.
Name – Staff Person (First, MI, Last)
Position
Date – MANTOUX Tuberculin Skin Test
Results – MANTOUX Tuberculin Skin Test
If test was positive, was a chest X-ray completed?
Yes
No
Comments:
AUTHORIZATION
I certify, based upon my examination, that this person appears to be free of disability, communicable disease or illness transmitted through
normal contact which would interfere with the staff person's ability to work with or care for residents.
Name – Examining Health Professional (Type or Print)
SIGNATURE – Physician, Physician’s Assistant or Health Check Provider
Address – Health Professional's Office (Street, City, State, Zip Code)
Date – Examination
DEPARTMENT OF CHILDREN AND FAMILIES
Division of Safety and Permanence
DCF-F-CFS0384 (R. 04/2010)
STAFF HEALTH REPORT – CHILD WELFARE FACILITIES
Use of form: Use of this form is voluntary. However, completion of this form by a physician, physician’s assistant or HealthCheck provider
meets the requirements of DCF 52.12(3)(e), 57.15(2)(c) and 59.04(1)(b)3. This form or its equivalent must be completed and on file prior to
staff working with residents. Personally identifiable information gathered on this form will be used only to verify compliance with licensing
rules. Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04(1)(m), Wisconsin Statutes].
Instructions: Each staff person shall present this form or its equivalent to the physician, physician’s assistant or HealthCheck provider to be
filled out and signed upon completion of the required health examination. The child welfare facility shall file the completed health report in the
staff person’s personnel record.
Name – Staff Person (First, MI, Last)
Position
Date – MANTOUX Tuberculin Skin Test
Results – MANTOUX Tuberculin Skin Test
If test was positive, was a chest X-ray completed?
Yes
No
Comments:
AUTHORIZATION
I certify, based upon my examination, that this person appears to be free of disability, communicable disease or illness transmitted through
normal contact which would interfere with the staff person's ability to work with or care for residents.
Name – Examining Health Professional (Type or Print)
SIGNATURE – Physician, Physician’s Assistant or Health Check Provider
Address – Health Professional's Office (Street, City, State, Zip Code)
Date – Examination