Medical/Physical Statements

Colorado Child Care Employees ONLY. Meets the Child Care Licensing Rule 7.702.41 General Requirements for All Personnel H.-J.

Scheduling Your Appointment

Complete a medical history survey designed specifically for childcare. A Registered Nurse or Physician will review your answers.

Next, choose your precautionary phone call appointment. We only call if you list a medical condition in your medical history. You will receive your Medical/Physical Statement by email within 24 hours after your appointment time. 

Doctor asking a patient to sign a typed form on a clipboard acknowledging test results, an

Registration 

$39.00

1. Fill out form. Directors may not fill out this form for their employees.

2. Schedule your precautionary phone call appointment.

Medical History Survey

My job responsibilities may include the following. Check all that apply.
Do you have any medical, mental, physical, or communicable disease conditions that could interfere with your ability to safely work with children?
Do you have any of the following medical conditions? Check all that apply
Do you have any of the following communicable disease conditions? Check all that apply
Do you experience any of the follow physical limitations? Check all that apply
Do you have enough strength to pick up the children you work with and carry them a short distance?
Are you currently under any medically prescribed work restrictions?
Currently, has your employer made any modifications to your job duties because of your medical condition?
Did you receive all your childhood immunizations?
Do you agree to immediately contact your doctor for any changes to your physical, mental, or emotional health that could interfere with you safely working with children?