Kansas Form Ccl 029 PDF Details

Ensuring the health and safety of children in child care settings is a paramount concern, and the Kansas CCL 029 form plays a critical role in this endeavor. This comprehensive document, a product of the Kansas Department of Health and Environment, reflects a meticulous approach to gather essential health data for children enrolled in licensed child care facilities. With sections dedicated to medical records, immunization history, and a child health assessment, the form is designed to provide a thorough health overview for each child, including those of providers. A detailed immunization record is required, adhering to the Advisory Committee on Immunization Practices' recommendations, ensuring children are protected against various diseases. Interestingly, the form also addresses exemptions for immunizations under specific conditions, showcasing a thoughtful consideration of individual circumstances. The inclusion of an exhaustive child health assessment further underscores the commitment to child welfare, requiring a licensed physician or nurse's evaluation. The form's structure, requiring detailed inputs from parents and guardians about the child's health, allergies, and even emergency medical preferences, ensures that child care providers are well-informed and prepared to offer the safest and most nurturing environment possible.

QuestionAnswer
Form NameKansas Form Ccl 029
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namesCCL_029_ _029a_Child_Med ical_Record_Imm unization_Histo ry_ _Health_Assessment ks department of health and environment form ccl 010 fillable

Form Preview Example

CCL. 029

Kansas Department of Health and Environment

Rev. 8/2011

Bureau of Child Care and Health Facilities

 

Child Care Licensing Program

 

1000 SW Jackson, Suite 200

 

Topeka, KS 66612-1274

 

Phone (785) 296-1270 Fax (785) 296-0803

 

Website: www.kdheks.gov/kidsnet

MEDI CAL RECORD FOR ALL CHI LDREN I N CHI LD CARE FACI LI TI ES,

I NCLUDI NG PROVI DER’S OWN CHI LDREN

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

Child’s First Day in Child Care

 

 

 

 

Name of Child Care Facilit y

 

 

 

 

 

 

Child’s Name

 

 

 

 

 

Date of Birth

 

 

 

Gender

 

 

 

 

 

First

Last

 

 

 

 

 

 

MM/ DD/ YYYY

 

 

 

M/ F

 

Parent/ Guardian I nformation

 

 

 

 

Parent/ Guardian I nformation

 

 

 

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 aut horized to pick up the child or to notify in case of emergency. I nclude 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) ? I f yes, provide information on Aut horization for Emergency Medical Care form CCL. 010.

 

 

Allergies

 

Frequent sore throats/ colds

 

 

 

 

Ear Aches

 

 

Asthma

 

Speech, Visual, Hearing

 

 

 

 

Diabetes

 

 

Epilepsy/ Seizures

 

Other

 

 

 

 

 

 

I f 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 t he person caring for your child.

Parent/ Guardian Signature:____ ____________ ___________________ ______ Date:_________ ____

1

History of I mmunizations

Required for all children in child care facilities, including the provider’s ow n children. A Kansas Certificate of I mmunizations ( 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 I mmunization Practices ( ACI P) .

Vaccine

 

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

 

1 st

 

2 nd

3 rd

4 th

5 th

 

6 th

DTaP/ DT/ Td/ Tdap (Diphtheria,

 

 

 

 

 

 

 

 

Tetanus, Pertussis)

 

 

 

 

 

 

 

 

Polio

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MMR (Measles, Mumps, and Rubella

 

 

 

 

 

 

 

 

combined)

 

 

 

 

 

 

 

 

HBV (Hepatitis B Vaccine)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Hx of Disease:

 

 

Date of I llness:

Varicella (Chicken Pox)

 

 

 

Physician Signature

 

 

 

 

 

 

 

 

 

 

 

 

HI B (Hemophilus I nfluenzae Type B)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PCV7 (Pneumococcal Conjugate)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HEP A (Hepatitis A)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Rotavirus * * Recommended < 8 mo of

 

 

 

 

 

 

 

 

age; not required

 

 

 

 

 

 

 

 

I nfluenza( Flu) * * Recommended

 

 

 

 

 

 

 

 

annually > 6 mo of age; not required

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Section I I .

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

Section I I . Complete Section below only if your child is exempted from law s 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 w ould endanger child’s life:

Exempt from following immunizations:

 

DTP

 

 

Pertussis Only ____Tetanus ____Polio

MMR

Rubella Only

Hep A

 

Hep B

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Hib

 

 

_PCV7 ____Ot her

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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 w hose teachings are opposed to immunizations.

Section I I I .

Parent/ Guardian Signature:____ ____________ ___________________ ______ Date:_________ _______

2

CCL. 029a

Rev. 08/2011

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. I f a Physician Assistant (PA) completes the Child Health Assessment, t he 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_________ __________

First

Last

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: ______ I N/ CM

% I LE_______

Weight: _____ LB/ KB % I LE_______

 

Physical Examination

 

I f Normal

I f 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 I ndividual Signing Above

 

Phone Number

 

 

 

Address

City

Zip Code

 

 

 

3