Health Questionnaire – Child Care Centers

Health Questionnaire – Child Care Centers
All staff, including the director, must complete a health questionnaire annually following the initial medical report. Substitute providers and volunteers must complete a health questionnaire on or before the first day of work and annually thereafter.
Full name of individual:*
Home address:*
Street Address, City & Zip Code
Phone Number*

Area CodePhone Number
Email:*
example@example.com
I certify that I am emotionally and physically fit to care for children.
Date:*

MonthDayYear
Date
Signature*

Clear
***This portion of the form to be completed by the Child Care Center Director***

As the director, I understand that I may request another evaluation of a staff member’s emotional and physical fitness to care for children when there is reason to believe that there has been a deterioration in the staff member’s emotional or physical fitness to care for children. This request may be made based upon factors such as observations of myself or other staff members, reports of concern from family, reports from law enforcement, or reports from medical personal. Child Care Rule 10A NCAC 09 .0701(b).
Date:

MonthDayYear
Date
This information must be included in the staff member’s medical file, which must be maintained separately from the staff member’s individual personnel file in the center. Child Care Rule 10A NCAC 09 .0701(d)
Should be Empty: