Form Ccl029 PDF Details

Form Ccl029 is a form used to report greenhouse gas emissions. When completed, the form will provide your company with an overview of its greenhouse gas emissions. The form can be used to help your business develop and implement a reduction strategy for greenhouse gas emissions. Completing the form is a required step in obtaining ISO certification. Your Business Name _________________________________ 1) What gases does this activity emit? Please list all gases emitted by your company during this activity, even if they are minor sources. Carbon dioxide (CO2), methane (CH4), nitrous oxide (N2O), hydrofluorocarbons (HFCs), perfluorocarbons (PFCs), sulfur hexafluoride (SF6) __ 2) What percentage of total emissions do these gases represent? __% 3) Estimated annual emissions from this activity: metric tons CO2e 4) Protocol(s): CDM/JI/CER Please choose the appropriate protocol(s). If you are unsure or there is more than one option, please select "other." CDM, JI, CER Other 5) List any

QuestionAnswer
Form NameForm Ccl029
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other nameskansas medical record child, kansas medical child care form, kansas 029, kansas ccl medical search

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CCL. 029

Kansas Department of Health and Environment

Rev. 3/2018

Bureau of Family Health

 

Child Care Licensing Program

 

1000 SW Jackson, Suite 200

 

Topeka, KS 66612-1274

 

Phone (785) 296-1270 Fax (785) 559-4244

 

Website: www.kdheks.gov/kidsnet

MEDICAL RECORD FOR ALL CHILDREN IN CHILD CARE FACILITIES,

INCLUDING PROVIDER’S OWN CHILDREN

Parents are to complete the Medical Record and the History of Immunizations for each child in licensed child care facilities. The Medical Record, History of Immunizations, and Child Health Assessment are transferable when the child moves to another licensed child care facility.

Child’s First Day in Child Care

 

 

 

 

Name of Child Care Facility

 

 

 

 

 

 

Child’s Name

 

 

 

 

 

Date of Birth

 

 

__Gender

 

 

 

 

 

 

 

First

Last

 

 

 

 

 

 

 

 

 

MM/DD/YYYY

 

 

M/F

 

Parent/Guardian Information

 

 

 

 

Parent/Guardian Information

Name

 

 

 

 

 

Name

 

 

 

 

 

 

Home Address

 

 

 

 

 

Home Address

 

 

 

 

 

 

 

 

 

 

 

Street

City

Zip Code

 

 

 

 

 

Street

City

Zip Code

Home Phone Number

 

 

 

 

 

Home Phone Number

 

 

 

 

 

 

Work Address

 

 

 

 

 

Work Address

 

 

 

 

 

 

 

 

 

 

 

Street

City

Zip Code

 

 

 

 

 

Street

City

Zip Code

Work Phone Number

 

 

 

 

 

Work Phone Number

 

 

 

 

 

 

Cell Phone Number

 

 

 

 

 

Cell Phone Number

 

 

 

 

 

 

E-mail Address

 

 

 

 

 

E-mail Address

 

 

 

 

 

 

Best way to contact

 

 

 

 

 

Best way to contact

 

 

 

 

 

 

Names and ages of children in family

Persons authorized to pick up the child or to notify in case of emergency. Include name, address, and telephone number. Attach an additional page, if necessary.

Child’s Physician

 

Phone Number

Child’s Dentist

 

 

Phone Number

Hospital Preference (for emergencies)

Has your physician approved the use of any non-prescription medications for your child such as acetaminophen, cough syrup, or ointments that can be given by the child care provider? No Yes, as follows:

Does your child have any of the following conditions (yes or no)? If yes, provide information on Authorization for Emergency Medical Care form CCL. 010.

 

 

Allergies

 

Frequent sore throats/colds

 

 

 

 

Ear Aches

 

 

Asthma

 

Speech, Visual, Hearing

 

 

 

 

Diabetes

 

 

Epilepsy/Seizures

 

Other

 

 

 

 

 

 

If yes answered to any above, please provide additional information

 

 

 

 

 

 

Have there been major changes at home that might affect your child in care?

 

No

 

Yes, as follows:

Please provide additional information or special instructions that will help the person caring for your child.

Parent/Guardian Signature: _________________________________________Date: _____________

1

History of Immunizations

Required for all children in child care facilities, including the provider’s own children. A Kansas Certificate of Immunizations (KCI) may be substituted for this form and attached to the completed Medical Record.

Child’s Name:

 

Date of Birth:

 

First

Last

 

MM/DD/YYYY

Section I. For a recommended schedule of immunizations, refer to the current schedule published by the Advisory Committee on Immunization Practices (ACIP).

Vaccine

 

Record the Month. Day and Year that each Dose of Vaccine was Received

 

1st

 

2nd

3rd

4th

5th

 

6th

Diphtheria, Tetanus, Pertussis

 

 

 

 

 

 

 

 

(DTaP)

 

 

 

 

 

 

 

 

Poliomyelitis (IPV/OPV)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Measles, Mumps, Rubella (MMR)

 

 

 

 

 

 

 

 

Hepatitis B (HepB)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Hx of Disease:

 

 

Date of Illness:

Varicella (VAR)

 

 

 

Physician Signature

 

 

 

 

 

 

 

 

 

 

 

 

Hemophilus Influenzae Type B (Hib)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Pneumococcal Conjugate (PCV)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Hepatitis A (HepA)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Rotavirus **Recommended <8 mo of

 

 

 

 

 

 

 

 

age; not required

 

 

 

 

 

 

 

 

Influenza(Flu) ** Recommended

 

 

 

 

 

 

 

 

annually >6 mo of age; not required

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Section II.

Complete this section only if your child is exempted from the law requiring immunizations [K.S.A. 65-508(d)].

Section II. Complete Section below only if your child is exempted from laws requiring requiring

The following two options are the ONLY exemptions allowed by law. Please check either (A) or (B) below and immunizations [ K.S.A. 65-508(d) and K.S.A. 65-519(c) ]

complete as required:

(A) Certification from licensed physician stating that immunization would endanger child’s life:

Exempt from following immunizations:

 

DTaP/DT _____Tdap/TD

 

Pertussis Only ____Polio

MMR

HepA

HepB

Hib

 

 

 

 

 

 

 

 

 

 

 

 

 

_____PCV ____Varicella ___Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Physician’s Signature (required): ________________________________________________Date:_______________

(B) My child is exempt under the law from immunizations. As the Parent or Legal Guardian, I state that I am an adherent of a religious denomination whose teachings are opposed to immunizations.

Section III.

Parent/Guardian Signature: ________________________________________Date:________________

2

CCL. 029a

Rev. 3/2017

Child Health Assessment

The Child Health Assessment form is to be completed and signed by a nurse approved by KDHE to perform Child Health Assessments or a Licensed Physician. If a Physician Assistant (PA) completes the Child Health Assessment, the signature of the Licensed Physician authorizing the PA is to be included at the bottom of this form.

A Child Health Assessment, recorded on a KDHE Form or other acceptable Forms mentioned below, is required for all children including children of the provider or staff in Licensed Day Care Homes, Group Day Care Homes, Child Care Centers and Preschools. A Kan-Be-Healthy Assessment Form is a KDHE Form and is acceptable, a Physician Health Assessment Form is acceptable, and a School Health Assessment Form is acceptable for school-age children or youth. The Health Assessment Form used should be attached to the KDHE Medical Record Form (CCL. 029).

Child’s Name_________________________________________ Date of Birth___________________

FirstLast

Health history and medical information pertinent to routine child care and emergencies (describe, if any):

None

Do you see this child for regular health supervision:

Yes No

Allergies to food or medicine (describe, if any):

None

List current medications (if any):

None

 

Length/Height: ______IN/CM

%ILE_______

Weight: _____LB/KG %ILE_______

 

Physical Examination

 

✓ If Normal

If Abnormal - Comments

 

 

 

 

 

 

Head/Ears/Eyes/Nose/Throat

 

 

 

 

 

 

 

 

 

Teeth

 

 

 

 

 

 

 

 

 

Cardio/Respiratory

 

 

 

 

 

 

 

 

 

Abdomen/GI

 

 

 

 

 

 

 

 

 

Genitalia/Breasts

 

 

 

 

 

 

 

 

 

Extremities/Joints/Back/Chest

 

 

 

 

 

 

 

 

 

Skin/Lymph Nodes

 

 

 

 

 

 

 

 

 

Neurologic & Developmental

 

 

 

 

 

 

 

 

 

Screening Tests

 

Screening Date

Note Here if Results are Pending or Abnormal

 

 

 

 

 

 

Lead

 

 

 

 

 

 

 

 

 

Anemia (HGB/HCT)

 

 

 

 

 

 

 

 

 

Urinalysis (UA)

 

 

 

 

 

 

 

 

 

Hearing

 

 

 

 

 

 

 

 

 

Vision

 

 

 

 

 

 

 

 

Health Problems or Special Needs, Recommended Treatment/Medications/Special Care (Attach additional sheets if necessary)

None

Signature of Licensed Physician or Nurse approved for Child Health Assessments

Date

 

 

 

Print the Name of the Individual Signing Above

 

Phone Number

 

 

 

Address

City

Zip Code

 

 

 

3

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