Form HS 0120 is a form that is used to apply for a state tax exemption. This form can be used by any individual or business who wants to be exempt from paying taxes on certain items or services. There are many different reasons that someone might want to use this form, and the instructions for filling it out can be a little bit confusing. In this blog post, we will go over everything you need to know about Form HS 0120 so that you can confidently fill it out and submit it to the state. We'll also provide some tips on how to make the process as easy as possible. Thanks for reading!
| Question | Answer |
|---|---|
| Form Name | Form Hs 0120 |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | tennessee hs child, tn provider medical form, tennessee child care provider medical, tennessee medical report form |
STATE OF TENNESSEE
DEPARTMENT OF HUMAN SERVICES
CHILD CARE PROVIDER MEDICAL REPORT
A. TO BE COMPLETED BY PROVIDER:
Name: _________________________________________________ Birth Date: ______________________________
Address: ________________________________________________________________________________________
StreetCityState Zip Code
I, _________________________________, hereby authorize the physician(s) name below to release information
(Provider/Patient’s Signature)
to the Department of Human Services for approval/licensure or employment as a child care provider.
Name of Physician(s): |
Address: |
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Purpose of Examination:
Initial Employment
Type of Activity In Child Care (check all that apply):
Caregiver Food Preparation Driver Facility Maintenance
Other: __________________________________________________
B. TO BE COMPLETED BY PHYSICIAN(S):
1. |
How long have you known this patient or have had knowledge of their medical history? ________________________ |
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2. |
In your opinion, does this person have: |
YES |
NO |
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a. The ability to lift 40 pounds? |
__________ |
__________ |
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b. The agility to move quickly to keep pace with toddlers? |
__________ |
__________ |
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c. The stamina to remain alert and energetic for 8 hours or more? |
__________ |
__________ |
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d. Any condition which requires restriction of activity or which could |
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affect patient’s temperament and interaction with children? |
__________ |
__________ |
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(If so, explain in Number 3) |
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3.Specify any physical, mental, or emotional limitation affecting this person’s ability to care for a group of children.
__________________________________________________________________________________________________
__________________________________________________________________________________________________
4. Is this patient currently taking any medications which could affect their work role or interaction with children?
Yes |
No If yes, please explain: _______________________________________________________________ |
__________________________________________________________________________________________________
5.Additional Comments: ____________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
_______________________________________________ |
__________________________________________ |
Physician’s Signature |
Date |
_______________________________________________ |
__________________________________________ |
Physician’s Signature |
Date |
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