Staying Healthy in Child Care - National Health and Medical ...

Sample report form for parent/doctor
Make copies of this letter for easy use
Child Care Centre: ________________________________________________________
Address: ________________________________________________________________
Contact person: __________________________________________________________
Phone: _________________________________________________________________
Dear Parent/Doctor,
Re: (child’s name) ________________________________Date of birth: ____/____/____
Child has: (comments, including time observed, number of times, severity)
Vomiting
Diarrhoea
Rash (description of rash and where rash started)
Other
There has/has not been recent similar illness in other children in the centre.
The diagnosis in the other children was:
The child’s temperature was ____° C taken under the child’s arm at ___________(time).
The child has eaten_______________________________________________________
The child has drunk ______________________________________________________
The child last passed urine at ____________ (time).
Parent contacted by_____________________________________ at __________ (time).
Signed:
_________________________________________________________________
Date: ___________ Time_________
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