Part A has the provider authorize the physician(s) to release information to the Department of Human Services for approval/licensure or employment as a child care provider.
Item 2: in your opinion, does this person have the agility to move quickly to keep pace with toddlers?
Stamina: in your opinion, does this person have the stamina to remain alert and energetic for 8 hours or more?
Item 3: specify any physical, mental, or emotional limitation affecting this person's ability to care for a group of children.
Item 4: is this patient currently taking any medications which could affect their work role or interaction with children?
| Question | Answer |
|---|---|
| Form Name | HS-0120 |
| Form Length | 1 page |
| Fillable? | Yes |
| Fillable fields | 25 |
| Avg. time to fill out | 5 min |
| Edition | Rev 01-21 |
| Issuing agency | Tennessee Department of Human Services |
| Matches the agency's file | Yes, checked October 2, 2026 |
| Other names | HS-0120, HS0120, Form HS-0120, Child Care Provider Medical Report, Tennessee DHS physical form |
| Official source | HS-0120 (Rev 01-21), Tennessee Department of Human Services |
Form Hs 0120 isn’t the one you’re looking for?