DSS Form 2901 at a glance
What it is: The South Carolina Department of Social Services Child Care Regulatory Services MEDICAL STATEMENT is to be completed by staff, volunteers, and emergency personnel.
Who signs: Sign on the Signature line and enter the Date.
A filled-in DSS Form 2901 example: a new employee fills out the medical statement
How to fill out DSS Form 2901, box by box
Your name, address and date of birth
Enter your Name (Last, First, Middle) and SSN.
Enter your Home Address: Number, Street, City, State and Zip.
Enter your Date of Birth, mark Male or Female, and enter your Telephone.
Your present health
Write a Statement of your present health in your own words.
Illnesses and conditions
Have you ever had or do you now have any of the following: mark Yes or No for each Illness/Condition.
Vision Problems, Rupture or Hernia, Hemorrhoids, Sugar or Albumen in Urine, Jaundice, Diabetes, Heart Problems, Bone, Joint or other Deformity, Back Problems, Tumor, Growth or Cancer, Nervous Condition, Drug or Narcotic Habit, Adverse Reaction to Medication, Alcoholism, Illnesses or injury not mentioned in the Illness/Condition list, Loss of consciousness.
Ear, Nose, Throat Problems, Hearing Loss, Frequent/Severe Headaches, Dizziness or Fainting Spells, Head Injury, Epilepsy or Seizures, Shortness of Breath or Lung Problems, Spitting up Blood, Tuberculosis, Skin Disease, Pain or Pressure in Chest, High Blood Pressure, Frequent Indigestion, Stomach, Liver or Intestinal Problems. Mark Yes or No for: Have you ever been refused employment or been unable to hold a job for reasons of health? Have you ever been denied life insurance? Have you ever been rejected for or discharged from military service for physical, mental or other reasons?
If any item is checked Yes, please explain
If any item is checked “Yes”, please explain.
Tuberculosis (TB) information
Please provide appropriate information regarding freedom from tuberculosis (TB). NEW EMPLOYEE: Enter date of written evidence from a physician or health resource attesting you are free from communicable TB, under Date of Verification.
CURRENT EMPLOYEE: Check if you are required to have additional tuberculosis tests: No more TB tests required, or TB tests required every.
Certify that the information is true and complete
Certify that the information supplied by you is true and complete to the best of your knowledge.
More rules for DSS Form 2901
DSS Form 2901 (OCT 07) Edition of JUL 82 is obsolete.
Sources
[1] DSS Form 2901 (OCT 07), Medical Statement, South Carolina Department of Social Services (the Official source link on this page).