DESSA (Drug and Substance Services Administration) is a government organization that provides health assessments for people who use drugs and/or alcohol. This form is used to help assess an individual's physical, mental, and social well-being. It can be used to help identify any concerns or problems, and to recommend treatment if necessary. The form should be filled out by a professional who has knowledge of the individual's history with drug and alcohol abuse.
| 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.