Get SC DSS 2926 2009-2024

Employees are also at risk of exposure to live virus such as polio and CMV. Comments Print Name Address of Health Care Provider Telephone Number Signature of Health Care Provider Date of Examination HEALTH ASSESSMENTS MUST BE OBTAINED AT LEAST EVERY FOUR 4 YEARS AFTER INITIAL ASSESSMENT AND SUBSEQUENTLY ACCORDING TO THE STATUTE. DSS Form 2926 JUN 09 Edition of NOV 99 is obsolete. South Carolina Department of Social Services Child Care Regulatory Services STAFF HEALTH ASSESSMENT Name DOB Type of Activity in Child Care Check all applicable Adult Member of Household Food Preparation Caring for Children Driver of Vehicle Desk Work Facility Maintenance THIS SECTION TO BE COMPLETED BY HEALTH PROFESSIONAL WHO DOES HEALTH ASSESSMENT Part I Medical History Does this person have any of the following medical problems Yes No History of myocardial infarction angina pectoris coronary insufficiency History of epilepsy Diabetes Current drug or alcohol dependency Disabling emotional disorder children or that might prohibit this person from providing adequate care for the children* If yes explain on reverse of form* Speech disorder Significant physical findings/chronic medical condition or physical impairment Other special medical problem or chronic disease which requires restriction of activity medication or which might affect his/her work role If so specify on reverse of form* Part II As shown by physical examination does the individual have At least 20/20 combined vision corrected by glasses if needed Normal hearing Normal blood pressure Part III Communicable Diseases If yes please comment Tuberculosis Certification If medically recommended or required by the Local Health Officer Type of Test Reading Date Immunization Status Facility staff are at risk of exposure to childhood diseases. Prospective employees who will work with infants should have a review of their immunization status. South Carolina Department of Social Services Child Care Regulatory Services STAFF HEALTH ASSESSMENT Name DOB Type of Activity in Child Care Check all applicable Adult Member of Household Food Preparation Caring for Children Driver of Vehicle Desk Work Facility Maintenance THIS SECTION TO BE COMPLETED BY HEALTH PROFESSIONAL WHO DOES HEALTH ASSESSMENT Part I Medical History Does this person have any of the following medical problems Yes No History of myocardial infarction angina pectoris coronary insufficiency History of epilepsy Diabetes Current drug or alcohol dependency Disabling emotional disorder children or that might prohibit this person from providing adequate care for the children* If yes explain on reverse of form* Speech disorder Significant physical findings/chronic medical condition or physical impairment Other special medical problem or chronic disease which requires restriction of activity medication or which might affect his/her work role If so specify on reverse of form* Part II As shown by physical examination does the individual have At least 20/20 combined vision corrected by glasses if needed Normal hearing Normal blood pressure Part III Communicable Diseases If yes please comment Tuberculosis Certification If medically recommended or required by the Local Health Officer Type of Test Reading Date Immunization Status Facility staff are at risk of exposure to childhood diseases. Prospective employees who will work with infants should have a review of their immunization status. .