NEW YORK CITY DEPARTMENT OF HEALTH AND MENTAL HYGIENE
BUREAU OF CHILD CARE
STAFF HEALTH FORM
Initial employment and every 2 years, a health examination is required for all teaching and non-teaching staff members, including
volunteers and students who regularly associate with children. Attach any additional documentation to this form.
Date of Employment
/ /
Date of Exam
/ /
(Last) (First) (Middle) SEX DATE DATE OF BIRTH
F
M
M
M
/ /
(No.) (Street) (City/Boro) (State) (Zip)
TELEPHONE: JOB TITLE AREA EMPLOYED
AC ( )
PAST MEDICAL HISTORY
Please check YES or NO
YES NO
M
M
Hypertension
M
M
Heart Disease
M
M
Diabetes
M
M
Seizure Disorder
M
M
Chronic Lung Disease
M
M
Mental Illness
M
M
Alcohol Abuse
M
M
Substance Abuse
M
M
Physical Disabilities
M
M
Allergies
M
M
Hepatitis
M
M
OTHER (SPECIFY)
MEDICAL PROVIDER SECTION
TOBACCO USE
M
Current
M
Former
M
None
If current, referred for cessation services?
M
Yes
M
No
Counselled re: No Smoking
M
Yes
M
No
PHYSICAL EXAM: (Please note any conditions or findings considered abnormal or requiring medical follow-up)
Height
Weight
Blood Pressure
/
Agency Stamp
Please explain any positive findings, list and explain any chronic
medications or therapies:
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TUBERCULIN TESTING (Not required for employment)
TUBERCULIN SKIN TEST: PPD MANTOUX (5 TU)
OR
BLOOD TEST: QUANTEFERON GOLD
Staff exempt from testing if they
Had a positive reaction to a PPD/Mantoux test or history of TB.
History of BCG vaccine does not exempt a staff member from TB screening.
All positive tuberculin tests in persons whose previous PPD/Mantoux was negative, require a chest X-ray and evaluation if treatment is indicated.
All positive tuberculin tests (PPD Mantoux 10 mm or over) require a report of one chest X-ray, (H.C. 49.06).
CHEST X-RAY: DONE AT:
DATE: RESULTS:
TREATMENT:
LABORATORY TESTS (Optional) (Specify tests ordered) DATE RESULTS
DIAGNOSIS/PROBLEM PLAN/FOLLOW-UP (For each diagnosis)
1.
2.
3.
4.
5.
1.
2.
3.
4.
5.
On the basis of my findings as indicated above and my knowledge of the staff member, I find that the above person is fit to give
adequate child care to children in a day care setting at this time.
Provider’s Name (Print) License No. Telephone No.
(Of Supervisor if NP or PA)
Address: Date of Exam
Provider’s Signature Staff Signature
NOTE TO THE DAY CARE CENTER: Staff Health Records are confidential and must be kept separate from all other records. Records of
required medical examinations must be kept on file at the day care center as long as staff members are employed. They must be returned to
them upon their request when their employment is terminated. In cases where chest x-rays are required, x-ray reports must be kept on file at the
day care center as long as the person is employed and two years thereafter.
(New York City Health Code Section 45.09)
DATE TESTED:
DATE INTERPRETED:
RESULTS:
DATE:
DATE:
Staff Name _________________________________________ D.O.B._________
/
_________
/
_________
IMMUNIZATION RECORD
Staff are required to have evidence of immunity to the diseases below through either documented vaccines, blood test documenting immunity,
or provider-documented history of illness (except where shaded in grey). Records should be kept in the staff person’s file.
Documentation of
Immunity
Vaccine Name Vaccine Date 1 Vaccine Date 2
Blood Test Documenting
Immunity (Yes / No)
Provider-Documented History
of Illness (Yes / No)
Tdap (Tetanus-
diphtheria-acellular
pertussis)
Rubella
Measles*
Mumps*
Varicella*
*Two doses of vaccine are required at least 28 days apart
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