HEALTH SCREENING REPORT (B)–FOSTER PARENTS130

VARIETY CHILDREN & FAMILY SERVICES INC
HEALTH SCREENING REPORT (B)–FOSTER PARENTS

1.All personnel or foster care applicants of child care facilities must demonstrate that their health condition allows them to perform the type of work required. This physical screening is to be completed by a licensed physician. A health screening by a licensed physician must have been performed not more than one year prior to current application for employment/certification

2.AUTHORIZATION FOR THE RELEASE OF MEDICAL INFORMATION

I HEREBY AUTHORIZE THE RELEASE OF MY MEDICAL INFORMATION CONTAINED IN THIS REPORT OR ANY OTHER REPORT FOR THE LAST 10 YEARS, TO VARIETY CHILDREN & FAMILY SERVICES.

3.NOTE TO PHYSICIAN: All personnel of child Care Facilities must be free from communicable Disease and must be capable of performing assigned tasks. Please complete the following information on the above referenced person.

HEALTH SCREENING REPORT (B)–FOSTER PARENTS

1. Name

First

Last

DATE OF BIRTH :

AGE:

POSITION/TITLE:

PART TIME/FULL TIME POSITION:

2. Signature Of Applicant// Foster Parent:

Date:

Address:

Phone:

Evaluation of General Health

Evaluation of ability to perform the above duty statement

Note any health condition that would create a hazard to children or other personnel --------------------------------------------------------------------------------------------------------------------------------------

Date of TB Test:

Positive

Negative

( Action taken if positive):

Date of Health Screen:

Signature of Physician:

Phone:

If you are human, leave this field blank.

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