Kansas Form Ccl 029 – Fill Out and Use This PDF

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:_________ ____

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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:_________ _______

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