OCFS-6004 (7/2015) FRONT

NEW YORK STATE

OFFICE OF CHILDREN AND FAMILY SERVICES

STAFF, VOLUNTEER, AND HOUSEHOLD MEMBER MEDICAL STATEMENT

Child Day Care Programs

INSTRUCTIONS:

A signature is required on BOTH sides of this form. If the only role is a household member, complete front page only.

Only a health care provider (physician, physician's assistant, nurse practitioner) may complete/sign the Medical Status section.

A registered nurse is NOT authorized to sign the Medical Status section but CAN sign the TB Test Information.

A health care professional may use an equivalent form as long as the information on this form is included.

See additional instructions about the tuberculin test on the reverse side.

Please PRINT clearly.

Program Name:

Facility ID Number:

Person’s Name:

Date of Birth:

Type of Program:	Family Day Care, Group Family Day Care and Small Day Care Centers	Day Care Center and

School-Age Child Care	All Programs
ROLE:

Provider	Substitute	Director	Volunteer	Employee

Assistant
Group Teacher
Household Member (GFDC/FDC)	Assistant Teacher
Typical Child Day Care Duties

Lifting and carrying children	Driver of vehicle	Facility maintenance
Close contact with children	Food preparation	Evacuation of children in an emergency
Direct supervision of children	Desk work

Following to be completed by Health Care Provider ONLY

Medical Status

To the best of my knowledge of the above-named individual, I find that:
He/She is currently exhibiting signs of a communicable disease that would pose a risk to the health and safety of children in care.	YES	NO
He/She has a diagnosed psychiatric or emotional disorder that would pose a risk to the health and safety of children in care.	YES	NO
He/She has a physical condition that would prevent him/her from providing typical child day care duties as described above.	YES	NO	NA (if only role is volunteer or household member)
For any “YES” responses, clarify and/or indicate restrictions:

Signature (physician, physician's assistant, nurse practitioner)
Title
/ /
Name (Please PRINT clearly or use office stamp)
Date of Exam
( ) -
/ /
Phone
Date of Signature

(Continued on reverse side)

OCFS-6004 (7/2015) REVERSE

NEW YORK STATE

OFFICE OF CHILDREN AND FAMILY SERVICES

STAFF, VOLUNTEER, AND HOUSEHOLD MEMBER

MEDICAL STATEMENT (continued)

Program Name:

Facility ID Number:

Person’s Name:

Date of Birth:

INSTRUCTIONS:

Household members in a family-based program that have no other role do not need to have a Tuberculin Test and do not need to complete this page.

A health care professional (physician, physician's assistant, nurse practitioner or a registered nurse as part of their duties at a health care facility), may enter the results in the Tuberculin Test Information section and sign this page.

Acceptable Tuberculin tests include Mantoux or other federally approved tuberculin test.

Please PRINT clearly.

Following to be completed by Health Professional ONLY

Tuberculin Test Information

Test Completed
Test Read on:	/ /
(mm / dd / yyyy)
Test Result:	Positive	Negative	mm
If Positive, does this person’s contact with children enrolled in child care pose a risk to the children’s

health and safety? Yes No
Test Not Completed

Not Tested. Provide reason:
Medical Exemption or Contraindication
If test result was previously Positive, indicate date:	/ /
(mm / dd / yyyy)

If previously Positive, does this person’s contact with children enrolled in child care pose a risk to the children’s health and safety?

Yes No

Signature (physician, physician's assistant, nurse practitioner or registered nurse)
Name (Please PRINT clearly or use office stamp)
Title
( ) -
/ /
Phone
Date
INSTRUCTIONS FOR PROGRAMS TO RETURN THE FORM:

GFDC/FDC programs: return this completed form to your Licensor or Registrar.

DCC/SACC programs: for Directors-return this completed form to your Licensor or Registrar; for all other staff - return the form to the Director for evaluation.

OCFS-6004 (7/2015) FRONT

2015-09-14