Please rate Lic 603 Form 6-22
This information may be obtained from the applicant, or his/her authorized representative. (Relatives, social agency, hospital or physician may assist the applicant in completing this form.)
Ambulatory: able to demonstrate the mental and physical ability to leave a building without the assistance of a person or the use of a mechanical device.
Health history: list currently prescribed medications and major illnesses, surgery, accidents; specify whether hospitalized and length of hospitalization in last 5 years.
Tuberculosis: any history of tuberculosis in applicant's family? Any recent exposure to anyone with tuberculosis?
| Question | Answer |
|---|---|
| Form Name | Form LIC 603 |
| Form Length | 3 pages |
| Fillable? | Yes |
| Fillable fields | 106 |
| Avg. time to fill out | 18 min |
| Edition | 6/22 |
| Issuing agency | California Department of Social Services |
| Not a substitute for | Physician's Report (LIC 602) |
| Matches the agency's file | Yes, checked October 2, 2026 |
| Other names | LIC 603, LIC603, LIC-603, Form LIC 603, LIC 603 form, Preplacement Appraisal Information |
| Official source | Form LIC 603 (Rev 6/22), California Department of Social Services |
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Please rate Lic 603 Form 6-22
