The DSS Health Assessment form, designed by the South Carolina Department of Social Services, specifically for Child Care Regulatory Services, plays a pivotal role in ensuring the well-being and safety of children in child care settings. This comprehensive form focuses on evaluating the health status of individuals involved in child care through various capacities, including direct care, food preparation, and maintenance, among others. It is structured to be filled out in parts, with the initial section capturing personal details and the kind of activities the individual will engage in at the child care facility. A significant portion is reserved for a health professional to complete, which covers a detailed medical history, physical examination findings, and an evaluation of communicable diseases, vital for preventing any potential health risks to children. Moreover, the form addresses the importance of candidates having a current review of their immunization status, given the high exposure risk to childhood illnesses within child care environments. Completing this form accurately and periodically, as mandated at least every four years, is crucial for maintaining a healthy and secure setting for children, staff, and household members involved in any child care services.
| Question | Answer |
|---|---|
| Form Name | Dss Health Assessment Form |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | dss form2926, form dss 2926 form, dss form 2926, form dss 2926 staff health assessment |
South Carolina Department of Social Services
Child Care Regulatory Services
STAFF HEALTH ASSESSMENT
Name: |
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DOB: |
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Type of Activity in Child Care: (Check all applicable) |
Caring for Children |
Desk Work |
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Adult Member of Household |
Food Preparation |
Driver of Vehicle |
Facility Maintenance |
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THIS SECTION TO BE COMPLETED BY HEALTH PROFESSIONAL WHO DOES HEALTH ASSESSMENT |
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Part I – Medical History |
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Does this person have any of the following medical problems? |
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Yes |
No |
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History of myocardial infarction, angina pectoris, coronary insufficiency? |
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History of epilepsy? |
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Diabetes? |
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Current drug or alcohol dependency? |
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Disabling emotional disorder? |
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Does this person have any special medical or mental problems which might interfere with the health of the |
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children or that might prohibit this person from providing adequate care for the children. If yes, explain on |
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reverse of form. |
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Speech disorder? |
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Significant physical findings/chronic medical condition or physical impairment? |
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Other special medical problem or chronic disease which requires restriction of activity, medication or |
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which might affect his/her work role? If so, specify on reverse of form. |
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Part II |
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As shown by physical examination, does the individual have: |
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Yes |
No |
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At least 20/20 combined vision, corrected by glasses if needed? |
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Normal hearing? |
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Normal blood pressure? |
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Part III – Communicable Diseases
Does this person have a communicable disease which would prohibit him/her from working in a child care facility?
Yes |
No If yes, please comment: |
Tuberculosis Certification (If medically recommended or required by the Local Health Officer)
Type of Test: |
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Reading: |
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Date: |
Immunization Status
Facility staff are at risk of exposure to childhood diseases. Prospective employees who will work with infants should have a review of their immunization status. Employees are also at risk of exposure to live virus, such as polio and CMV.
Immunization status reviewed: |
Yes |
No |
Comments:
Print Name & Address of Health Care Provider |
Telephone Number |
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Signature of Health Care Provider |
Date of Examination |
HEALTH ASSESSMENTS MUST BE OBTAINED AT LEAST EVERY FOUR (4) YEARS AFTER INITIAL ASSESSMENT AND SUBSEQUENTLY ACCORDING TO THE STATUTE.
DSS Form 2926 (JUN 09) Edition of NOV 99 is obsolete.