Health Screening Report Form PDF Details

If you are like most people, you probably think of health screenings as a way to detect problems early on and prevent them from becoming worse. While this is certainly one benefit of health screenings, there is another important reason for getting them: to create a record of your health history. A health screening report form can be an important tool for tracking your health over time and ensuring that any potential issues are caught early. In this blog post, we will discuss the benefits of having a health screening report form and provide some tips for completing one.

Below is the information about the form you were looking for to complete. It will show you the span of time you'll need to fill out health screening report form, what fields you need to fill in, and so on.

QuestionAnswer
Form NameHealth Screening Report Form
Form Length1 pages
Fillable?Yes
Fillable fields52
Avg. time to fill out10 min 43 sec
Other nameshealth screening report lic 503, lic 503, lic503, lic health screening

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

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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

 

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LIC 503 (3/99) (PERSONAL)

How to Edit Health Screening Report Form Online for Free

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 lic 503 form fields to fill out

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