CCL 029 at a glance
What it is: CCL 029 is the Kansas Department of Health and Environment Licensing Medical Record.
Who signs: The Child Health Assessment form is to be completed and signed by a nurse approved to perform health assessments, a licensed physician, or physician's assistant (PA).
A filled-in CCL 029 example: a parent completes the Medical History
How to fill out CCL 029, box by box
Child's First Day in Child Care
In accordance with K.A.R. 28-4-117, a completed medical record shall be on file for all children in care under 10 years of age and all children living in the home under 16 years of age. The Medical Record shall include a Medical History including current Immunizations and a Child Health Assessment. The Medical Record is transferable when the child moves to another licensed child care facility. Enter the Child's First Day in Child Care, the Name of Child Care Facility, the Child's Name (First Last), the Date of Birth (MM/DD/YYYY), the Gender (M/F) and the Parent/Guardian Information.
Parent/Guardian Information
Enter the Name, the Home Address (Street City Zip Code), the Home/Cell Phone Number, the Work Phone Number, the E-mail Address and the Best way to contact.
Persons authorized to pick up the child or to notify in case of emergency
Under Persons authorized to pick up the child or to notify in case of emergency (other than the parents), enter the Name, Address and Phone Number.
Child's Physician and Hospital Preference (for emergencies)
Enter the Child's Physician with the Phone Number, and the Hospital Preference (for emergencies).
Any known allergies or medical conditions of child
Enter any known allergies or medical conditions of the child.
Enter any major changes at home that might affect your child in care.
Under Please provide additional information or special instructions that will help the person caring for your child, enter the information or instructions.
Parent/Guardian Signature
Sign on the Parent/Guardian Signature line and enter the Date.
Date of annual review
In each row, enter the Date of annual review, the Parent/Guardian Initials and the Provider Initials.
Medical History Cont. - Immunizations
The Medical History Cont. - Immunizations page is required for all children in child care facilities, including the provider's own children.
Enter the Child's Name (First Last) and the Date of Birth (MM/DD/YYYY) for Section I.
Record the Month, Day and Year that each Dose of Vaccine was Received.
The vaccines are Diphtheria, Tetanus, Pertussis; Poliomyelitis (IPV/OPV); Measles, Mumps, Rubella (MMR); Hepatitis B; Varicella (VAR); Hemophilus Influenzae Type B (Hib); Pneumococcal Conjugate (PCV); and Hepatitis A.
The Hx of Disease lines ask for the Date of Illness and the Physician Signature.
Rotavirus is marked **Recommended <8 mo.; not required, and Influenza (Flu) is marked **Recommended annually >6 mo.; not required.
For a recommended schedule of immunizations, refer to the current schedule published by the Advisory Committee on Immunization Practices (ACIP).
A Kansas Certificate of Immunizations (KCI) may be substituted for this form and attached to the completed Medical Record.
Section II. Exemption from the law requiring immunizations
Complete Section II only if your child is exempted from laws requiring immunizations [K.S.A. 65-519(c) and K.S.A. 65-508(d)] or from the law requiring immunizations [K.S.A. 65-508(g)].
The following two options are the ONLY exemptions allowed by law: check either (A) or (B) and complete as required.
(A) is a Certification from licensed physician stating that immunization would endanger child's life: mark Exempt from following immunizations (DTaP/DT, Tdap/TD, Pertussis Only, Polio, MMR, Hep A, Hep B, Hib, PCV, Varicella, Other) and add the Physician's Signature (required) and the Date.
(B) My child is exempt under the law from immunizations, and states that the Parent or Legal Guardian is an adherent of a religious denomination whose teachings are opposed to immunizations.
Section III is the Parent/Guardian Signature and the Date.
Child Health Assessment
The health assessment shall be conducted not more than 12 months before and no later than 60 calendar days after enrollment at the child care facility.
A Child Health Assessment, recorded on a KDHE Form or other acceptable Forms mentioned in the Child Health Assessment section, is required for all children including children of the provider or staff in Family Child 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.
Enter the Child's Name and Date of Birth; describe health history and medical information pertinent to routine child care and emergencies, allergies to food or medicine, and current medications, if any, or mark None; and mark Yes or No for Do you see this child for regular health supervision.
Enter Length/Height in IN/CM and Weight in LB/KG, each with %ILE; for Head/Ears/Eyes/Nose/Throat, Teeth, Cardio/Respiratory, Abdomen/GI, Genitalia/Breasts, Extremities/Joints/Back/Chest, Skin/Lymph Nodes and Neurologic & Developmental, fill in If Normal or If Abnormal - Comments.
For the Screening Tests Lead, Anemia (HGB/HCT), Urinalysis (UA), Hearing and Vision, enter the Screening Date and Note Here if Results are Pending or Abnormal.
For Health Problems or Special Needs, Recommended Treatment/Medications/Special Care (Attach additional pages if necessary), enter them or mark None; then add the Signature of Licensed Physician or Nurse approved for Child Health Assessment, the Date, the Print the Name of the Individual Signing the Signature line, the Phone Number and the Address City Zip Code.
Sources
[1] CCL 029 (Rev. 07/2024), Licensing Medical Record, Kansas Department of Health and Environment (the Official source link on this page).