Transcription of HEALTH SCREENING REPORT - FACILITY PERSONNEL
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HEALTH SCREENING REPORT - FACILITY PERSONNEL
DATE OF HEALTH SCREENINGNAME OF PHYSICIAN (PHYSICIAN S STAMP)DATEHEALTH SCREENING BY: (ORIGINAL SIGNATURE)TELEPHONE #DATE Infants Adults Developmentally Disabled Physically Handicapped Children Elderly Mentally Disordered Drug/Alcohol Addiction Other(specify)_____STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCYCALIFORNIA DEPARTMENT OF SOCIAL SERVICESCOMMUNITY CARE LICENSING DIVISIONHEALTH SCREENING REPORT - FACILITY PERSONNELAll PERSONNEL , including applicant, licensee or employed staff ofResidential Care Facilities for the Elderly, Community Care or ChildCare Facilities must demonstrate that their HEALTH condition allows themto perform the type of work required. This HEALTH appraisal is to becompleted by or under the direction of a HEALTH SCREENING , by or under the direction of a physician musthave been performed not more than one year prior to employmentor within seven (7) days after NAMEFACILITY ADDRESSPERSON'S NAMEAGEPOSITION TITLETYPE OF FACILITYWORK DAYS PER WEEKWORK HOURS PER DAYDUTY STATEMENTTYPES OF PERSONS SERVED (Check appropriate items)AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATIONI HEREBY AUTHORIZE THE RELEASE OF MEDICAL INFORMATION CONTAINED IN THIS OF APPLICANT/LICENSEE OR EMPLOYEEADDRESSDATENOTE TO PHYSICIAN: PERSONNEL in Residential Care Facilities for the Elderly, Community Care or Child Care Facilities shall be fr
DATE OF HEALTH SCREENING NAME OF PHYSICIAN (PHYSICIAN’S STAMP) DATE HEALTH SCREENING BY: (ORIGINAL SIGNATURE) TELEPHONE # DATE Infants Adults Developmentally Disabled Physically Handicapped Children Elderly Mentally …
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