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Get TN HS-0120 2009-2024

STATE OF TENNESSEE DEPARTMENT OF HUMAN SERVICES CHILD CARE PROVIDER MEDICAL REPORT A. TO BE COMPLETED BY PROVIDER Name Birth Date Address Street City State Zip Code I hereby authorize the physician s name below to release information Provider/Patient s Signature to the Department of Human Services for approval/licensure or employment as a child care provider. Address Name of Physician s Purpose of Examination Initial Employment Type of Activity In Child Care check all that apply Caregiver Food Preparation Driver Facility Maintenance Other Re-examination 1. How long have you known this patient or have had knowledge of their medical history 2. In your opinion does this person have a* The ability to lift 40 pounds b. The agility to move quickly to keep pace with toddlers c* The stamina to remain alert and energetic for 8 hours or more d. Any condition which requires restriction of activity or which could affect patient s temperament and interaction with children If so explain in Number 3 YES NO 3. Specify any physical mental or emotional limitation affecting this person s ability to care for a group of children* 4. Is this patient currently taking any medications which could affect their work role or interaction with children Yes No If yes please explain 5. Address Name of Physician s Purpose of Examination Initial Employment Type of Activity In Child Care check all that apply Caregiver Food Preparation Driver Facility Maintenance Other Re-examination 1. How long have you known this patient or have had knowledge of their medical history 2. In your opinion does this person have a* The ability to lift 40 pounds b. How long have you known this patient or have had knowledge of their medical history 2. In your opinion does this person have a* The ability to lift 40 pounds b. The agility to move quickly to keep pace with toddlers c* The stamina to remain alert and energetic for 8 hours or more d. The agility to move quickly to keep pace with toddlers c* The stamina to remain alert and energetic for 8 hours or more d. Any condition which requires restriction of activity or which could affect patient s temperament and interaction with children If so explain in Number 3 YES NO 3. Any condition which requires restriction of activity or which could affect patient s temperament and interaction with children If so explain in Number 3 YES NO 3. Specify any physical mental or emotional limitation affecting this person s ability to care for a group of children* 4. Specify any physical mental or emotional limitation affecting this person s ability to care for a group of children* 4. Is this patient currently taking any medications which could affect their work role or interaction with children Yes No If yes please explain 5. Address Name of Physician s Purpose of Examination Initial Employment Type of Activity In Child Care check all that apply Caregiver Food Preparation Driver Facility Maintenance Other Re-examination 1. How long have you known this patient or have had knowledge of their medical history 2. In your opinion does this person have a* The ability to lift 40 pounds b. The agility to move quickly to keep pace with toddlers c* The stamina to remain alert and energetic for 8 hours or more d. .

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