Medical Record and Authorization For Emergency Medical Care Form

CCL. 029Rev. 8/2011Kansas Department of Health and EnvironmentBureau of Child Care and Health FacilitiesChild Care Licensing Program1000 SW Jackson, Suite 200Topeka, KS 66612-1274Phone (785) 296-1270 Fax (785) 296-0803Website: www.kdheks.gov/kidsnetMEDICAL RECORD FOR ALL CHILDREN IN CHILD CARE FACILITIES,INCLUDING PROVIDER’S OWN CHILDRENParents are to complete the Medical Record and the History of Immunizations for each child in licensed child carefacilities. The Medical Record, History of Immunizations, and Child Health Assessment are transferable when the childmoves to another licensed child care facility.Child’s First Day in Child CareName of Child Care FacilityChild’s Name Date of Birth GenderFirst Last MM/DD/YYYY M/FNameParent/Guardian InformationNameParent/Guardian InformationHome AddressHome Phone NumberWork AddressWork Phone NumberHome AddressStreet City Zip Code Street City Zip CodeHome Phone NumberWork AddressStreet City Zip Code Street City Zip CodeWork Phone NumberCell Phone NumberE-mail AddressBest way to contactCell Phone NumberE-mail AddressBest way to contactNames and ages of children in familyPersons authorized to pick up the child or to notify in case of emergency. Include name, address, and telephone number.Attach an additional page, if necessary.Child’s PhysicianChild’s DentistPhone NumberPhone NumberHospital Preference (for emergencies)Has your physician approved the use of any non-prescription medications for your child such as acetaminophen, coughsyrup, or ointments that can be given by the child care provider? No Yes, as follows:Does your child have any of the following conditions (yes or no)? If yes, provide information on Authorization forEmergency Medical Care form CCL. 010.Allergies Frequent sore throats/colds Ear AchesAsthma Speech, Visual, Hearing DiabetesEpilepsy/SeizuresOtherIf yes answered to any above, please provide additional informationHave there been major changes at home that might affect your child in care? No Yes, as follows:Please provide additional information or special instructions that will help the person caring for your child.Parent/Guardian Signature:_________________________________________Date:_____________1

CCL 010Rev. 7/2012Kansas Department of Health and EnvironmentBureau of Family Health1000 SW Jackson, Suite 200 * Topeka, KS 66612-1274Child Care Unit Phone: 785-296-1270 Fax: 785-296-0803Foster Care Unit Phone (785) 296-1270 Fax (785) 296-7025Website: www.kdheks.gov/kidsnet/Consult local hospital to be sure this form is acceptable. Written permission of the parent, guardian or legal custodian , foremergency medical treatment must be on file at facility for each child on a form that meets the requirements of the hospital orclinic where emergency care will be given.License or Certificate #___________________89In order to meet all legal requirements, I hereby authorize _________________________________________________________ and/or__________________________________who is (are) representative(s) of ______________________________________________________(Child Care Facility)to give consent for any and all necessary emergency medical care for my child _________________________________________________(Name)while said child is in said individual's custody between the dates of ________________________ and ____________________________Month Day Year Month Day Year________________________________________________________________(Signature of Parent or Guardian)Parent's signature needs notarization or witnessed if required by local hospital or clinic.________________________________________________________________(Witness)Hiersteiner Child Development Center staffHiersteiner Child Development Centeruntil further noticeState of KansasBefore me, the undersigned authority, on this day personally appeared _____________________________________________known to be the person whose name is subscribed above, and acknowledged to me that he/she executed the same for the purposetherein expressed.Sworn and subscribed before me this ________________________ day of ____________________________Year________.(SEAL) Notary Public__________________________________________.My Commission expires _________________________________.- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -Physician _____________________________ Address __________________________________ Phone ______________________Hospital Preference ____________________________________________________________________________________________Emergency Phone Numbers ______________________________________________________________________________________Home Father (work) Mother (work)Do you have Health Insurance? _______ Policy Name and Number ______________________________________________________Do you receive medical assistance? _______ Program and Care Number _________________________________________________Is child eligible for military medical care? _______ I.D. Number _________________________________________________________Medical Information on Child: (see attached information)(Attach this form to the child's health record. Both forms must be taken to the emergency room.)

History of ImmunizationsRequired for all children in child care facilities, including the provider’s own children. A Kansas Certificate ofImmunizations (KCI) may be substituted for this form and attached to the completed Medical Record.Child’s Name:Date of Birth:First Last MM/DD/YYYYSection I. For a recommended schedule of immunizations, refer to the current schedule published by theAdvisory Committee on Immunization Practices (ACIP).VaccineRecord the Month. Day and Year that each Dose of Vaccine was Received1 st 2 nd 3 rd 4 th 5 th 6 thDTaP/DT/Td/Tdap (Diphtheria,Tetanus, Pertussis)PolioMMR (Measles, Mumps, and Rubellacombined)HBV (Hepatitis B Vaccine)Varicella (Chicken Pox)HIB (Hemophilus Influenzae Type B)PCV7 (Pneumococcal Conjugate)HEP A (Hepatitis A)Rotavirus **Recommended 6 mo of age; not requiredHx of Disease:Physician SignatureDate of Illness:Section II.Complete this section only if your child is exempted from the law requiring immunizations [K.S.A. 65-508(d)].Section The following II. Complete two options Section are the below ONLY only exemptions if your child allowed is exempted by law. Please from check laws requiring either (A) requiring or (B) below andimmunizations complete as required: [ K.S.A. 65-508(d) and K.S.A. 65-519(c) ] (A) Certification from licensed physician stating that immunization would endanger child’s life:Exempt from following immunizations:HibDTP Pertussis Only ____Tetanus ____Polio MMR Rubella Only Hep A Hep B_PCV7 ____OtherPhysician’s Signature (required): ________________________________________________Date:_______________ (B) My child is exempt under the law from immunizations. As the Parent or Legal Guardian, I statethat I am an adherent of a religious denomination whose teachings are opposed to immunizations.Section III.Parent/Guardian Signature:_________________________________________Date:________________2

CCL. 029aRev. 08/2011Child Health AssessmentThe Child Health Assessment form is to be completed and signed by a nurse approved by KDHE to perform Child HealthAssessments or a Licensed Physician. If a Physician Assistant (PA) completes the Child Health Assessment, the signatureof the Licensed Physician authorizing the PA is to be included at the bottom of this form.A Child Health Assessment, recorded on a KDHE Form or other acceptable Forms mentioned below, is required for allchildren including children of the provider or staff in Licensed Day Care Homes, Group Day Care Homes, Child CareCenters and Preschools. A Kan-Be-Healthy Assessment Form is a KDHE Form and is acceptable, a Physician HealthAssessment Form is acceptable, and a School Health Assessment Form is acceptable for school-age children or youth.The Health Assessment Form used should be attached to the KDHE Medical Record Form (CCL. 029).Child’s Name_________________________________________FirstLastDate of Birth___________________Health history and medical information pertinent to routine child care and emergencies(describe, if any): NoneAllergies to food or medicine (describe, if any): NoneList current medications (if any): NoneDo you see this child for regularhealth supervision: Yes NoLength/Height: ______IN/CM %ILE_______ Weight: _____LB/KB %ILE_______Physical Examination If Normal If Abnormal - CommentsHead/Ears/Eyes/Nose/ThroatTeethCardio/RespiratoryAbdomen/GIGenitalia/BreastsExtremities/Joints/Back/ChestSkin/Lymph NodesNeurologic & DevelopmentalScreening Tests Screening Date Note Here if Results are Pending or AbnormalLeadAnemia (HGB/HCT)Urinalysis (UA)HearingVisionHealth Problems or Special Needs, Recommended Treatment/Medications/Special Care (Attach additional sheets if necessary) NoneSignature of Licensed Physician or Nurse approved for Child Health AssessmentsDatePrint the Name of the Individual Signing AbovePhone NumberAddress City Zip Code3