Health Screening Report Form PDF Details

The Health Screening Report form mandated by the State of California, under the auspices of the Health and Human Services Agency and the California Department of Social Services Community Care Licensing Division, serves as a crucial document for ensuring the health and safety within Residential Care Facilities for the Elderly, Community Care, or Child Care Facilities. This comprehensive form is designed to certify that all facility personnel, including applicants, licensees, or staff, are in satisfactory health to perform their duties effectively without posing any risk to themselves, clients, or their coworkers. The process necessitates a thorough health appraisal by a physician or a delegate to evaluate the general health of the individual and their capacity to fulfil the job's physical demands. The evaluation includes a Tuberculosis (TB) test and an assessment of any health conditions that might compromise the safety of the workplace environment. Moreover, the form caters to a broad demographic by including provisions for the care of infants, adults, children, the elderly, as well as individuals who are developmentally disabled, mentally disordered, physically handicapped, or coping with drug/alcohol addiction. The form also emphasizes the importance of confidentiality and consent through an authorization for the release of medical information, underscoring the ethical considerations inherent in such evaluations. By integrating these elements, the Health Screening Report form plays a pivotal role in promoting a safe and healthy care environment, underlining the importance of preventive health measures in the care sector.

QuestionAnswer
Form NameHealth Screening Report Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other nameshealth screening report, health screening report sample, health screening report form, lic 503 california

Form Preview Example

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

 

COMMUNITY CARE LICENSING DIVISION

HEALTH SCREENING REPORT - FACILITY PERSONNEL

All personnel, including applicant, licensee or employed staff of Residential Care Facilities for the Elderly, Community Care or Child Care Facilities must demonstrate that their health condition allows them to perform the type of work required. This health appraisal is to be completed by or under the direction of a physician.

A health screening, by or under the direction of a physician must have been performed not more than one year prior to employment or within seven (7) days after employment.

FACILITY NAME

FACILITY ADDRESS

PERSON'S NAME

AGE

POSITION TITLE

TYPE OF FACILITY

WORK DAYS PER WEEK

WORK HOURS PER DAY

DUTY STATEMENT

TYPES OF PERSONS SERVED (Check appropriate items)

■

Infants

■

Adults

■

Children

■

Elderly

■

■

Developmentally Disabled

Mentally Disordered

■

■

Physically Handicapped

Drug/Alcohol Addiction

■Other (specify) ______________________________________________________________________________________________

AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION

I HEREBY AUTHORIZE THE RELEASE OF MEDICAL INFORMATION CONTAINED IN THIS REPORT.

SIGNATURE OF APPLICANT/LICENSEE OR EMPLOYEE

▼

ADDRESS

DATE

NOTE TO PHYSICIAN: Personnel in Residential Care Facilities for the Elderly, Community Care or Child Care Facilities shall be free from communicable disease, and capable of performing assigned tasks. Please complete the following information on the above named person.

EVALUATION OF GENERAL HEALTH

EVALUATION OF ABILITY TO PERFORM WORK DESCRIBED IN THE ABOVE DUTY STATEMENT

NOTE ANY HEALTH CONDITION THAT WOULD CREATE A HAZARD TO THE PERSON, CLIENTS, CHILDREN OR OTHER PERSONNEL

 

DATE OF T.B. TEST

■ POSITIVE

ACTION TAKEN (IF POSITIVE)

 

 

 

 

 

 

 

 

 

 

 

■ NEGATIVE

 

 

 

 

 

DATE OF HEALTH SCREENING

 

NAME OF PHYSICIAN (PHYSICIAN’S STAMP)

 

DATE

 

 

 

 

 

 

 

 

 

 

HEALTH SCREENING BY: (ORIGINAL SIGNATURE)

TELEPHONE #

DATE

 

▼

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LIC 503 (3/99) (PERSONAL)

How to Edit Health Screening Report Form Online for Free

This PDF editor was built with the objective of allowing it to be as effortless and intuitive as possible. The following steps are going to make filling out the health screening report sample simple.

Step 1: The following web page contains an orange button saying "Get Form Now". Please click it.

Step 2: The document editing page is currently open. Include information or manage existing details.

Create the following parts to create the document:

health screening report facility personnel fields to fill out

The software will require you to submit the NOTE TO PHYSICIAN Personnel in, EVALUATION OF GENERAL HEALTH, EVALUATION OF ABILITY TO PERFORM, NOTE ANY HEALTH CONDITION THAT, DATE OF TB TEST, ACTION TAKEN IF POSITIVE, POSITIVE, NEGATIVE, DATE OF HEALTH SCREENING, NAME OF PHYSICIAN PHYSICIANS STAMP, and DATE box.

Finishing health screening report facility personnel step 2

Write down the crucial information in HEALTH SCREENING BY ORIGINAL, TELEPHONE, LIC PERSONAL, and DATE area.

Finishing health screening report facility personnel part 3

Step 3: Hit the button "Done". The PDF document may be exported. It is possible to upload it to your computer or send it by email.

Step 4: To avoid any kind of complications in the long run, you should have a minimum of several duplicates of your document.

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