Get Ia 470-5152_dsa 2023-2025

The IA 470-5152_DSA form is essential for documenting the health status of child care providers. This guide will provide clear, step-by-step instructions on how to accurately complete this important online form.

Follow the steps to successfully fill out the IA 470-5152_DSA form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling in the 'Name' and 'Date of Exam' fields at the top of the form. Ensure that the name corresponds with the individual who requires the examination.
3. In the section titled 'Immunization Status,' review the immunization history and check the appropriate box to indicate whether the individual is current with all ACIP recommended immunizations or if they have declined certain vaccinations.
4. Complete the 'Tuberculosis Screening' section. Assess for current symptoms of TB and risk factors. The physician should indicate whether a TST or IGRA test is completed and provide the respective dates.
5. Fill out the 'Overall Health Status' questions. Indicate whether there is any known communicable disease or other health condition that poses a threat to children’s safety and the ability to supervise multiple dependent children.
6. Provide the conclusion regarding the individual's ability to engage in child care. Choose from the options given and describe any necessary accommodations or restrictions if applicable.
7. Have the health care provider sign and fill out their details at the bottom of the form, including their type (MD, DO, PA, ARNP, or DC) and contact information.
8. Once the form is complete, review all entries for accuracy. Users can save changes, download, print, or share the form as needed.

Complete your documentation today by filling out the IA 470-5152_DSA form online.