Ner OR a registered nurse) Name (Please PRINT clearly) Title ( ) Phone Date / / Yes No .
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How to fill out the LDSS-4434-1 online
The LDSS-4434-1 is an essential document used for submitting a caregiver medical statement related to child day care. This guide provides clear, step-by-step instructions to assist users in completing the form accurately and efficiently online.
Follow the steps to fill out the LDSS-4434-1 online.
- Press the 'Get Form' button to access the LDSS-4434-1 form and open it in your online editing tool.
- Provide the applicant's name and date of birth in the designated fields to ensure accurate identification.
- In the medical condition section, the health care provider must indicate whether the applicant is physically fit to care for children, ensuring to check the appropriate 'Yes' or 'No' box.
- The health care provider also needs to confirm the absence of communicable diseases and emotional or psychological disorders by checking 'Yes' or 'No' for the relevant questions.
- If any 'No' responses are provided, clearly indicate any restrictions in the space provided.
- Have the health care provider sign the document, including their printed name, phone number, title, and the date of examination.
- For the tuberculosis (TB) section, only a qualified health professional should fill out the Mantoux test information, including the test result and read date.
- If the applicant has tested positive for TB, the health professional must assess if there is a risk to the children and provide their signature, title, phone number, and date of completion.
- Once all sections of the form have been completed, save your changes, and consider downloading or printing the form for your records or submissions.
Start completing your LDSS-4434-1 form online today for a seamless submission process.
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