2.7: Child Care Staff Health Assessment

Employee Health Assessment Form (Physician Evaluation)

To Be Completed by Employer

 

Employee Information

Name:

 Position: 

 Date of Birth 

Date of Assessment:

Supervisor's Name:

 

Activities This Position May Require the Employee to Perform

Activity	Required for Position
Lifting or carrying children (up to 40 lbs)	☐ Yes ☐ No
Standing or walking for extended periods	☐ Yes ☐ No
Bending, crouching, or kneeling	☐ Yes ☐ No
Pushing or pulling objects (e.g., strollers, carts)	☐ Yes ☐ No
Climbing stairs or ladders	☐ Yes ☐ No
Sitting on the floor with children	☐ Yes ☐ No
Engaging in outdoor activities	☐ Yes ☐ No
Administering first aid or CPR	☐ Yes ☐ No
Using cleaning or sanitizing products	☐ Yes ☐ No
Preparing or serving food	☐ Yes ☐ No

 

To Be Completed by Physician

Health Screening

Health Indicator	Assessment	Comments/Notes
General Physical Health	☐ Satisfactory	________________________________________
Respiratory Health (e.g., free from cough, wheezing)	☐ Satisfactory	________________________________________
Vision (adequate for child supervision)	☐ Satisfactory	________________________________________
Hearing (adequate for child supervision)	☐ Satisfactory	________________________________________
Cardiovascular Health (e.g., free from heart issues)	☐ Satisfactory	________________________________________
Musculoskeletal Health (e.g., able to lift, stand, move)	☐ Satisfactory	________________________________________
Skin Condition (free from contagious conditions)	☐ Satisfactory	________________________________________

 

Immunization Record

Vaccine	Date Administered	Up-to-Date (Y/N)	Comments
Measles, Mumps, and Rubella (MMR)	__________________	☐ Yes ☐ No	________________________________________
Tetanus, Diphtheria, Pertussis (Tdap)	__________________	☐ Yes ☐ No	________________________________________
Varicella (Chickenpox)	__________________	☐ Yes ☐ No	________________________________________
Hepatitis B	__________________	☐ Yes ☐ No	________________________________________
Influenza (Annual)	__________________	☐ Yes ☐ No	________________________________________
COVID-19	__________________	☐ Yes ☐ No	________________________________________
Other (Specify): _________________	__________________	☐ Yes ☐ No	________________________________________

 

Tuberculosis (TB) Test

Test Type	Date Administered	Result	Comments
Tuberculin Skin Test (TST)	__________________	☐ Negative ☐ Positive	________________________________________
Interferon-Gamma Release Assay (IGRA)	__________________	☐ Negative ☐ Positive	________________________________________

 

Medical History

1. Does the employee have any known allergies?:
☐ Yes ☐ No

If yes, please specify:


2. Chronic conditions (e.g., diabetes, asthma, epilepsy):
☐ Yes ☐ No

If yes, please specify:


3. Is the employee currently taking any medications?:
☐ Yes ☐ No

If yes, list medications:


4. Any surgeries or hospitalizations in the past year?:
☐ Yes ☐ No

If yes, please specify:
 

5. Do they have any conditions that could affect their ability to care for children safely and effectively?:
☐ Yes ☐ No

If yes, please explain:

 

Mental Health and Stress Management

1. Do you believe the employee is currently experiencing any mental health conditions (e.g., stress, anxiety, depression) that may affect their work?:
☐ Yes ☐ No

If yes, please specify:

2. Does the employee have a support system to help manage stress (e.g., family, friends, professional help)?:
☐ Yes ☐ No

3. Has the employee received any counseling or mental health support in the past year?:
☐ Yes ☐ No

 

Infectious Disease and Safety

1. Is the employee free from contagious diseases (e.g., cold, flu, COVID-19)?:
☐ Yes ☐ No

2. Has the employee been exposed to any contagious diseases in the past two weeks?:
☐ Yes ☐ No

If yes, please specify:

3. Do they practice good hygiene, including regular handwashing and sanitizing practices?:
☐ Yes ☐ No

 

Physician’s Recommendations

- Clearance for Employment:
☐ Cleared for employment without restrictions
☐ Cleared with the following restrictions:
☐ Not cleared for employment (follow-up required)

- Additional Recommendations or Follow-Up Actions:

 

Signatures

Employee's Signature:

Date:

 

Physician's Signature:

Date:

Physician’s Contact Information:

Phone Number:

 Email: