A child care staff health assessment form moves through three people before it’s complete: you fill in your personal health history, your employer checks off the physical demands of your job, and a licensed healthcare provider examines you, runs a tuberculosis test, reviews your immunizations, and signs a statement that you’re fit to care for children. Each section has to be done in that order, because the provider needs to know what your job actually involves before deciding whether you can do it safely.
The Three Sections and Who Fills Each One
Every state publishes its own version of the form (Pennsylvania’s CD 322, Maryland’s OCC 1204, California’s LIC 503, Missouri’s medical examination report, and so on), but the structure is consistent. The employee section covers health history. The employer section describes the job. The healthcare provider section documents the exam, TB screening, immunizations, and a suitability determination. If any of the three sections is missing, incomplete, or signed by the wrong person, the form will come back.
What You Complete as the Employee
Download the current version of the form directly from your state licensing agency’s website rather than using a photocopy from the facility’s filing cabinet. In Pennsylvania that agency is the Department of Human Services; in California it’s the Department of Social Services (Community Care Licensing); in Maryland it’s the Office of Child Care. An outdated edition is one of the most common reasons a form gets kicked back during inspection, even when the content looks the same as the current version.
Fill in your name, date of birth, and contact information. Mark the reason for the exam, which will be either initial employment or a periodic re-examination. Then work through the personal health history: past illnesses, surgeries, chronic conditions, medications you currently take, and allergies. Answer honestly. The provider relies on what you write to run a meaningful exam, and anything you leave off that surfaces later can cause problems with both the employer and the licensing agency.
What Your Employer Fills In Before Your Appointment
Before you take the form to the clinic, your employer completes a section listing the physical demands of your specific position. Expect checkboxes for lifting and carrying children, close interaction with children, food preparation, driving facility vehicles, and building maintenance. This step matters more than it looks. The healthcare provider evaluates your fitness against the duties you’ll actually perform, not a generic standard. If your role doesn’t involve lifting infants, the provider won’t hold you to that benchmark. If the employer section is blank when you arrive at the appointment, the provider is assessing you against nothing in particular, and that’s grounds for rejection.
What Happens at the Medical Appointment
Physical Examination
The provider conducts a standard physical, checking vision, hearing, and general physical condition, and screens for communicable diseases. Many forms also ask the provider to assess whether you have the strength and mobility to care for a particular age group. The demands of chasing toddlers, lifting infants, and keeping pace with school-age children are different, and the provider weighs your condition against whichever applies to your assignment.
Tuberculosis Screening
A TB test at initial employment is standard across nearly every state. Two methods are accepted: the tuberculin skin test (the Mantoux or TST method) and the interferon gamma release assay, which is a blood draw.1HeadStart.gov. Tuberculosis If you choose the skin test, you have to return to the office 48 to 72 hours later so the injection site can be read. A positive skin test triggers a chest X-ray and additional evaluation. Once you have a documented positive skin test with a negative X-ray on file, most states don’t require repeat TB testing unless you’re exposed to an active case or develop a persistent cough.
The form needs the test date, method, and result recorded in full. If the skin test came back positive, the official radiology report for the follow-up X-ray must be attached to the form.
Immunization Records
Bring your immunization records to the appointment. Many states require proof of vaccination against measles, mumps, and rubella (MMR) and pertussis, usually through the Tdap vaccine. Some states also require documentation of varicella (chickenpox) and hepatitis B. Influenza vaccination rules vary; certain jurisdictions mandate an annual flu shot, others recommend it, and some allow a signed declination. If you can’t locate your records, a blood titer test can confirm immunity for most of these vaccines.
Suitability Statement
At the end of the exam, the provider signs a statement confirming whether you’re suitable to provide child care. The form specifically asks the provider to flag any medical or emotional condition that could threaten children’s health or prevent you from delivering safe, adequate care. Substance abuse is called out explicitly on some state forms as something the provider should consider.
Who Can Sign the Form
Only a physician, physician assistant, or certified registered nurse practitioner can complete the medical section and sign off. A registered nurse operating independently, a chiropractor, or a naturopath generally doesn’t qualify. The signature has to include the professional title. A signature without “MD,” “PA-C,” or “CRNP” (or the equivalent credential your state recognizes) after it may not satisfy the regulation, and that single omission is enough to send the form back.
When It’s Due
Deadlines are set by state licensing regulations, so confirm yours before your start date. California requires the health screening to be completed no more than one year before employment or within seven days after starting work. Pennsylvania requires the assessment within 12 months before you begin providing service in a child care setting. Don’t assume you can start work and sort out the paperwork later. Most licensing agencies treat a missing health assessment the same way they treat an absent background check: the employee shouldn’t be in the building without one.
Where the Form Goes After the Appointment
Once the provider signs the form, hand it to the facility’s owner, director, or HR contact. The facility keeps the original. Under the Americans with Disabilities Act, medical records have to be stored separately from your general personnel file and treated as confidential; access is limited to supervisors who need to know about work restrictions, first aid personnel, and government officials investigating compliance.2U.S. Equal Employment Opportunity Commission. Enforcement Guidance on Disability-Related Inquiries and Medical Examinations of Employees under the ADA State licensing inspectors can review these files during routine inspections and will cite a facility for missing, expired, or improperly completed assessments. Some states allow off-site storage if a verification form at the facility identifies where the records are kept and who is responsible for them.
Who Pays for the Exam
There’s no single federal rule making the employer pay in every case, but several rules push that way. If an employer deducts the cost from a new hire’s first paycheck and the deduction drops pay below the minimum wage for that pay period, the deduction violates wage and hour protections. OSHA’s position on employer-mandated medical surveillance is clearer: when the employer requires a health screening, the employer makes it available at no cost to the employee.3Occupational Safety and Health Administration. OSHA Policy Regarding Medical Surveillance Requirements Many facilities handle this by arranging the exam through a contracted clinic or reimbursing the new hire. Out-of-pocket costs for an employment physical typically run between $60 and $300 depending on the clinic, your location, and whether insurance picks up any portion.
Check These Before You Leave the Clinic
Reviewing the form while you’re still at the medical office saves a second appointment later. Look for these common rejection points:
- You’re using the current version of your state’s form, not a prior edition.
- The provider’s signature is present, legible, and followed by a professional title.
- The provider is a physician, PA, or CRNP (not an RN working independently, a chiropractor, or a naturopath).
- The TB section lists the test date, method, and result. If the skin test was positive, the chest X-ray radiology report is attached.
- The employer section was filled in before the appointment, not left blank.
- The provider’s signature date is within your state’s validity window (not already expired on the day it’s signed).
Renewal
The initial assessment doesn’t last indefinitely. Most states require a periodic re-examination; Pennsylvania, for example, requires a new assessment every 24 months. The renewal covers the same ground as the first exam (physical, communicable disease check, suitability determination), with one usual exception: TB testing generally doesn’t need to be repeated unless a physician, the local health department, or specific circumstances direct otherwise. Put the expiration date on your calendar, because an expired assessment is treated the same as a missing one, and you’ll likely be pulled from direct care duties until it’s corrected.