Fillable Printable Child Care Medication Form - Massachusetts

Child Care Medication Form - Massachusetts

Page 1 of 2 FCCMedicalForm20101021

Family Child Care Medical Form

Dear Physician/Health Care Professional:

The Department of Early Education and Care requires that all persons who will be caring for children

in their homes or working as an assistant in a licensed family child care home be examined by a

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

eight children under the age of fourteen without any assistance provided two of the children are

school age.

Your patient, _____________________________________________________________, is required

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

form in its entirety and return it to your patient.

Name of patient: __________________________________________Date of birth: _____________

Address: __________________________________________________________________

__________________________________________________________________

Date of Examination:_________________________________________

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

please provide details of any of these limitations.

_________________________________________________________________________________

Page 2 of 2 FCCMedicalForm20101021

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

been treating this patient? ____________________________________________________________

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

Comments:________________________________________________________________________

Has this person been immunized in accordance with the requirements of the Department of Public

Health (Mumps, Measles and Rubella)?

________ Yes ________ No

Family child care educators may be 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

that re-vaccination may be medically contraindicated.

_________________________________________________________________________________

_______________________________________ __________________________________

Signature of Physician/Health Care Professional Please print your name, address,

telephone number, and license number

_______________________________________ __________________________________

Date

__________________________________

___________________________________