Bcal 3704 Form PDF Details

Bcal 3704 Form is an online application that allows California employers to report new hires and rehire information. The form is used to track employee's wages, hours, and other related information. The Bcal 3704 Form is a required form for all California employers. Failure to submit the form may result in penalties. The deadline to submit the Bcal 3704 Form is within 20 days of the employee's start date. For more information on how to complete the Bcal 3704 Form, visit our website.

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

How to Edit Bcal 3704 Form Online for Free

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Completing part 1 in bcal 3704 cc

2. Given that the last segment is done, it's time to insert the essential particulars in This individual is or will be, Has this Person Been Tested for TB, Date Tested, Test Type, Results, Yes, If Yes cid, Skin Test, XRay, Positive Explain in Comments, Negative, How would you describe the, No physicalmental condition or, Explain in Comments if reasonable, and Physicalmental condition or health so you're able to progress to the third stage.

Completing section 2 in bcal 3704 cc

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