Fillable Printable Child Care Medication Form - Massachusetts

Child Care Medication Form - Massachusetts

Page 1 of2 FCCMedicalForm20101021

FamilyChildCareMedicalForm

Dear Physician/Health Care Professional:

The Department ofEarly Education and Care requires that all persons who willbecaring for children

intheirhomes or working as an assistant ina licensed familychild care home beexaminedbya

physician/health care professional. EEC allows a licensee or a certified assistant to care for up to

eight childrenunder the age of fourteenwithout any assistanceprovided two of the children are

school age.

Yourpatient, _____________________________________________________________, is required

to submit this medical form as part of his/her licensing or certification requirement. Please fillout the

form in its entiretyandreturn ittoyourpatient.

Nameofpatient:__________________________________________Date ofbirth:_____________

Address:__________________________________________________________________

__________________________________________________________________

DateofExamination:_________________________________________

In your professional opinion what is the status of your patient’s general physical and mental health?

_________________________________________________________________________________

In your professional opinion does your patient have any limitations (for example side effects of

medication, inabilityto lift,etc.) that would affect his/her ability to work with young children? If yes,

please provide details of anyof these limitations.

_________________________________________________________________________________

Page2 of2 FCCMedicalForm20101021

Are you the patient’s treating physician/health care professional? _________ If so, how long have you

beentreatingthis patient?____________________________________________________________

If not, how many times have you seen this patient? ________________________________________

Comments:________________________________________________________________________

Has this person been immunized in accordance with therequirements ofthe Department of Public

Health (Mumps, Measles and Rubella)?

________ Yes ________ No

Familychild care educatorsmaybe granted a medical exemption if they are able to provide

documentation signed by a physician stating the specific medical exemption. Please indicate whether

your patient should be medically exempted from proving immunity to these diseases based on the fact

thatre-vaccination may be medically contraindicated.

_________________________________________________________________________________

_________________________________________________________________________

Signature ofPhysician/Health Care Professional Please print your name, address,

telephonenumber, and license number

_________________________________________________________________________

Date

__________________________________

___________________________________