Form LIC 701 Physician's Report - Child Care Centers - California

Form LIC701 is a California Department of Social Services form also known as the "Physician's Report - Child Care Centers". The latest edition of the form was released in August 1, 2008 and is available for digital filing.

Download an up-to-date fillable Form LIC701 in PDF-format down below or look it up on the California Department of Social Services Forms website.

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CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
STATE OF CALIFORNIA
COMMUNITY CARE LICENSING
HEALTH AND HUMAN SERVICES AGENCY
PHYSICIAN’S REPORT—CHILD CARE CENTERS
(CHILD’S PRE-ADMISSION HEALTH EVALUATION)
PART A – PARENT’S CONSENT
(TO BE COMPLETED BY PARENT)
__________________________________________, born ________________________________ is being studied for readiness to enter
(NAME OF CHILD)
(BIRTH DATE)
_________________________________________ . This Child Care Center/School provides a program which extends from _____ : ____
(NAME OF CHILD CARE CENTER/SCHOOL)
a.m./p.m. to ______ a.m./p.m. , __________ days a week.
Please provide a report on above-named child using the form below. I hereby authorize release of medical information contained in this
report to the above-named Child Care Center.
__________________________________________________________
_________________
(SIGNATURE OF PARENT, GUARDIAN, OR CHILD’S AUTHORIZED REPRESENTATIVE)
(TODAY’S DATE)
PART B – PHYSICIAN’S REPORT
(TO BE COMPLETED BY PHYSICIAN)
Problems of which you should be aware:
Hearing:
Allergies: medicine:
Vision:
Insect stings:
Developmental:
Food:
Language/Speech:
Asthma:
Dental:
Other (Include behavioral concerns):
Comments/Explanations:
MEDICATION PRESCRIBED/SPECIAL ROUTINES/RESTRICTIONS FOR THIS CHILD:
IMMUNIZATION HISTORY: (Fill out or enclose California Immunization Record, PM-298.)
DATE EACH DOSE WAS GIVEN
VACCINE
1st
2nd
3rd
4th
5th
POLIO (OPV OR IPV)
/
/
/
/
/
/
/
/
/
/
(DIPHTHERIA, TETANUS AND
DTP/DTaP/
[ACELLULAR] PERTUSSIS OR TETANUS
/
/
/
/
/
/
/
/
/
/
DT/Td
AND DIPHTHERIA ONLY)
(MEASLES, MUMPS, AND RUBELLA)
/
/
/
/
MMR
(REQUIRED FOR CHILD CARE ONLY)
/
/
/
/
/
/
/
/
(HAEMOPHILUS B)
HIB MENINGITIS
/
/
/
/
/
/
HEPATITIS B
/
/
/
/
VARICELLA
(CHICKENPOX)
SCREENING OF TB RISK FACTORS (listing on reverse side)
■ ■
Risk factors not present; TB skin test not required.
■ ■
Risk factors present; Mantoux TB skin test performed (unless
previous positive skin test documented).
___ Communicable TB disease not present.
■ ■
■ ■
I have
have not
reviewed the above information with the parent/guardian.
Physician:_______________________________________________
Date of Physical Exam: ___________________________________
Address:________________________________________________
Date This Form Completed: _______________________________
Telephone: ______________________________________________
Signature ______________________________________________
■ ■
■ ■
■ ■
Physician
Physician’s Assistant
Nurse Practitioner
LIC 701 (8/08) (Confidential)
PAGE 1 OF 2
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
STATE OF CALIFORNIA
COMMUNITY CARE LICENSING
HEALTH AND HUMAN SERVICES AGENCY
PHYSICIAN’S REPORT—CHILD CARE CENTERS
(CHILD’S PRE-ADMISSION HEALTH EVALUATION)
PART A – PARENT’S CONSENT
(TO BE COMPLETED BY PARENT)
__________________________________________, born ________________________________ is being studied for readiness to enter
(NAME OF CHILD)
(BIRTH DATE)
_________________________________________ . This Child Care Center/School provides a program which extends from _____ : ____
(NAME OF CHILD CARE CENTER/SCHOOL)
a.m./p.m. to ______ a.m./p.m. , __________ days a week.
Please provide a report on above-named child using the form below. I hereby authorize release of medical information contained in this
report to the above-named Child Care Center.
__________________________________________________________
_________________
(SIGNATURE OF PARENT, GUARDIAN, OR CHILD’S AUTHORIZED REPRESENTATIVE)
(TODAY’S DATE)
PART B – PHYSICIAN’S REPORT
(TO BE COMPLETED BY PHYSICIAN)
Problems of which you should be aware:
Hearing:
Allergies: medicine:
Vision:
Insect stings:
Developmental:
Food:
Language/Speech:
Asthma:
Dental:
Other (Include behavioral concerns):
Comments/Explanations:
MEDICATION PRESCRIBED/SPECIAL ROUTINES/RESTRICTIONS FOR THIS CHILD:
IMMUNIZATION HISTORY: (Fill out or enclose California Immunization Record, PM-298.)
DATE EACH DOSE WAS GIVEN
VACCINE
1st
2nd
3rd
4th
5th
POLIO (OPV OR IPV)
/
/
/
/
/
/
/
/
/
/
(DIPHTHERIA, TETANUS AND
DTP/DTaP/
[ACELLULAR] PERTUSSIS OR TETANUS
/
/
/
/
/
/
/
/
/
/
DT/Td
AND DIPHTHERIA ONLY)
(MEASLES, MUMPS, AND RUBELLA)
/
/
/
/
MMR
(REQUIRED FOR CHILD CARE ONLY)
/
/
/
/
/
/
/
/
(HAEMOPHILUS B)
HIB MENINGITIS
/
/
/
/
/
/
HEPATITIS B
/
/
/
/
VARICELLA
(CHICKENPOX)
SCREENING OF TB RISK FACTORS (listing on reverse side)
■ ■
Risk factors not present; TB skin test not required.
■ ■
Risk factors present; Mantoux TB skin test performed (unless
previous positive skin test documented).
___ Communicable TB disease not present.
■ ■
■ ■
I have
have not
reviewed the above information with the parent/guardian.
Physician:_______________________________________________
Date of Physical Exam: ___________________________________
Address:________________________________________________
Date This Form Completed: _______________________________
Telephone: ______________________________________________
Signature ______________________________________________
■ ■
■ ■
■ ■
Physician
Physician’s Assistant
Nurse Practitioner
LIC 701 (8/08) (Confidential)
PAGE 1 OF 2
RISK FACTORS FOR TB IN CHILDREN:
*
Have a family member or contacts with a history of confirmed or suspected TB.
*
Are in foreign-born families and from high-prevalence countries (Asia, Africa, Central and South America).
*
Live in out-of-home placements.
*
Have, or are suspected to have, HIV infection.
*
Live with an adult with HIV seropositivity.
*
Live with an adult who has been incarcerated in the last five years.
*
Live among, or are frequently exposed to, individuals who are homeless, migrant farm workers, users of street drugs, or residents in
nursing homes.
*
Have abnormalities on chest X-ray suggestive of TB.
*
Have clinical evidence of TB.
Consult with your local health department’s TB control program on any aspects of TB prevention and treatment.
LIC 701 (8/08) (Confidential)
PAGE 2 of 2
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