Bcal 3704 Form PDF Details

In the realm of caregiving, whether for children, adults, or dependent adults, ensuring the health and safety of those under care is paramount. The BCAL 3704 form plays a crucial role in this process, serving as a medical clearance request to the Michigan Department of Human Services, Bureau of Children and Adult Licensing. Primarily used by individuals seeking to work in facilities like adult foster care, child foster care, and child care centers, this document requires thorough information ranging from personal details of the applicant or licensee, such as their name, address, and social security number, to specific medical information provided by a physician. The form’s purpose is to establish that the individual's physical and mental health does not pose any risk to the health and safety of those they will be caring for. It covers testing for tuberculosis, general health conditions, and any potential limitations or accommodations needed. Designed to uphold stringent health standards, the completion and submission of this form are voluntary; however, failing to do so may result in the denial of a license application. The BCAL 3704 emphasizes the importance of transparency and health safety in environments where the vulnerable are cared for, reflecting the state’s commitment to protect its residents through diligent oversight.

QuestionAnswer
Form NameBcal 3704 Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesX-Ray, DHS, Licensing, suitability

Form Preview Example

If you have multiple individuals in the home that will require additional forms, please print additional copies of this form before filling it out.

MEDICAL CLEARANCE REQUEST

Michigan Department of Human Services

BUREAU of Children and Adult Licensing

APPLICANT/LICENSEE INFORMATION

Facility/Home Name

License Number

Facility/Home Address (Street Number and Name)

City

State

Zip Code

PLEASE MAIL TO

Licensing Consultant (Name, Address, Phone)

Department of Human Services

BUREAU of Children and Adult Licensing

7109 W. Saginaw, 2nd Floor

P.O. Box 30650

Lansing, MI 48909-8150

License Application Type

Adult Foster Care (24-Hour Care)

Child Foster Care (24-Hour Care) Child Care (Less Than 24-Hour Care)

Capacity _______________________________

PATIENT INFORMATION (To be Completed by Patient) (Please Print or Type)

Name (Last, First, Middle, Jr., II, etc.)

Date of Birth

Social Security Number

Telephone Number

 

 

 

 

 

Address (Street Number and Name)

City

 

State

Zip Code

 

 

 

 

 

RELEASE OF INFORMATION (To be Completed by Patient)

I authorize the release of medical information concerning me

Date

 

to the care facility listed above and to the Michigan

 

Department of Human Services, BUREAU of Children and Adult

Patient’s Signature

Licensing, for the purpose of determining my suitability to

 

provide or be associated with the care of children/dependent

 

Physician’s Name (Please PRINT or TYPE)

adults.

 

 

 

MEDICAL INFORMATION (To be Completed by Physician)

• This individual is, or will be, employed in a child/dependent adult care setting.

• It is necessary to establish that those providing care are in such physical and mental condition and health as not to adversely affect the health or safety of a child/dependent adult and the quality and manner of his/her care.

• To assist us in this determination, you are being asked to answer the following.

Has this Person Been Tested for T.B.?

Date Tested

Test Type

Results

No

Yes If Yes

Skin Test

X-Ray

Positive (Explain in Comments)

Negative

How would you describe the patient’s general physical/mental condition and health? (Use Comments section for explanations)

No physical/mental condition or health problem exists that would limit the ability to work with or around children/dependent adults.

Physical/mental condition or health problem exists that would not limit the ability to work with or around children/dependent adults. Explain in Comments if reasonable accommodation may be needed.

Physical/mental condition or health problem exists which would affect the ability to work with or around children/dependent adults, with or without reasonable accommodation.

Comments (Please use back of this form if additional space is needed.)

Would you like to be contacted by the licensing consultant regarding your recommendation?

Yes

No

 

 

 

 

 

 

Physician’s Signature

Signature Date

 

Telephone Number

Examination Date

 

 

 

 

 

 

Address (Street Number and Name)

City

 

 

State

Zip Code

 

 

 

 

 

AUTHORITY: 1973 PA 116

Department of

Human Services (DHS)

will not discriminate against any

individual or group because of race, sex, religion, age, national origin, color,

1979 PA 218

height, weight, marital status, political beliefs or disability. If you need help

RESPONSE: Voluntary

with reading, writing, hearing, etc., under the Americans with Disabilities Act,

PENALTY: Application for licensure may be denied.

you are invited to make your needs known to a DHS office in your area.

 

BCAL-3704 (REV. 10-07) Previous editions 3-05, 10-05 AND 1-07 may be used. MS Word

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Completing part 1 in bcal 3704 cc

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Completing section 2 in bcal 3704 cc

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