Cfs 602 Form PDF Details

In order to receive disability benefits from the Social Security Administration (SSA), you must file a Disability Insurance Application, Form SSA-601-BK. If you are filing for disability based on your own work record, you will use the Disability Insurance Application – Adult, Form SSA-602.This form is also used to apply for Supplemental Security Income (SSI) benefits. The SSI program is a needs-based program that provides monthly payments to low-income individuals who are aged, blind, or disabled. If you are filing for disability benefits based on another person’s work record, you will use the Disability Insurance Application – Claimant Representative, Form SSA-603. This form is used to request survivor

QuestionAnswer
Form NameCfs 602 Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namescfs 602 dcfs form, cfs602, cfs 602 illinois, dcfs cfs form 602

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CFS 602

Rev. 9/2002

STATE OF ILLINOIS

Department of Children and Family Services

MEDICAL REPORT ON AN ADULT IN A CHILD CARE FACILITY

(Includes employees and volunteers in DCFS licensed child care facilities, operators of day care/group day care homes and other adult members of their households)

(Name of Person Examined)

(Birth Date)

Position (check one)

Day Care/Group Day Care Home Caregiver

Child Care Staff

Other Staff in a Child Care Facility Member of Household

Name of Licensee/applicant for License or Licensed Facility where individual is employed/volunteers

Address

Food Handler (See Section B)

Child Care Facility Driver (See Section B) Volunteer in a Child Care Facility

 

Street

City

 

Zip Code

County

I. TESTS

Date

 

 

Results

Tuberculin test (by the Mantoux method or chest X-ray

 

 

 

 

in a positive reactor)*

 

 

 

 

Other (specify):

 

 

 

 

 

 

II.FINDINGS AND RECOMMENDATIONS

A.Findings

Summary of medical or emotional problems or conditions, if any, which may affect the individual’s ability to work, volunteer or reside in a facility caring for children.

B.Any conditions which contraindicate a person serving as a Food Handler or Child Care Facility Driver?

Yes No

If yes, please specify

C.Recommendations

The above individual was found free from symptoms of communicable disease and is otherwise medically and emotionally

fit to work, volunteer or reside in a facility caring for children. Yes No Explain “No”:

In my opinion, the individual could meet the strength and mobility challenges required for caring for a child in one or more of the age groups checked below:

0-2 years of age

2-6 years of age

7-12 years of age

12-18 years of age

Date of Examination

Physician’s Name (Print) and State License Number

 

 

 

 

 

 

 

 

Physician’s Signature

 

 

 

 

 

 

 

 

 

Street Address

City

State

Zip Code

 

 

 

 

 

 

Telephone Number

 

 

 

* Required in initial examination only. Physician to determine need for test in subsequent examinations.

REEXAMINATIONS

Date of Examination

 

Physician’s Name (Print) and State License Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of Examination

 

Physician’s Name (Print) and State License Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of Examination

 

Physician’s Name (Print) and State License Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of Examination

 

Physician’s Name (Print) and State License Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of Examination

 

Physician’s Name (Print) and State License Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of Examination

Physician’s Name (Print) and State License Number

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Simple tips to prepare medical report on an adult in a child care facility portion 1

2. Once the previous segment is complete, it's time to insert the necessary particulars in Summary of medical or emotional, B Any conditions which, Yes, If yes please specify, C Recommendations, The above individual was found, Yes, years of age, years of age, years of age, years of age, Date of Examination, Physicians Name Print and State, Physicians Signature, and Street Address so you're able to proceed further.

medical report on an adult in a child care facility conclusion process clarified (part 2)

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Completing section 3 of medical report on an adult in a child care facility

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medical report on an adult in a child care facility conclusion process detailed (step 4)

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Filling in segment 5 in medical report on an adult in a child care facility

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