Moa Health Form
ADVERTISEMENT
1HEALTH REQUIREMENTS
Child’s Name:
Date of Birth:
IMMUNIZATIONS
Date/Dose 1
Date/Dose 2
Date/Dose 3
Date/Booster
Date/Booster
DTP / DTaP / DT
POLIO
IPV or OPV
MEASLES
Rubeola / Serampion
MUMPS
RUBELLA
Hib
Hepatitis A
Hepatitis B
TB TEST
Positive
Negative
Date:
(if required)
Varicella
(see below)
Varicella (chickenpox) vaccine is not required if your child has had chickenpox disease. If your child has had chickenpox, please complete the
statement: My child had varicella disease (chickenpox) on or about (date) ______________ and does not need varicella vaccine.
_______________________________________________
_______________
Parent’s Signature
Date
Signature of Health Care Professional _________________________________________ Date: _______________
Signature of staff making handwritten copy of record ______________________________ Date: _______________
ADMISSION REQUIREMENT: One on the following must be presented when your child (under the age of 5 years) is admitted to the day care facility or
within one week of admission. Check to indelicate the option you select:
HEALTH-CARE PROFESSIONAL’S STATEMENT: I have examined the above named child within the past year and find that he/she is physically
able to take part in the day care program.
_________________________________________________________________________
__________________________
Health Care Professional’s Signature
Date
A copy of the medical screening form of the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) OR Texas Health Steps Program, if
no referral for further diagnosis and treatment is indicated.
A form or written statement from a health service or clinic.
If you do not have any of the above:
PARENT’S STATEMENT: My child has been examined within the past year by a health care professional and is able to participate in the day care
program:
Or
Within 12 months of admission, I will obtain a health care professional’s statement and will submit it to the day care facility.
OR
My child has an appointment for a physical examination:
Date:
Name and Address of health care professional:
I will submit the statement, from a health care professional to the child-care facility following the examination.
__________________________________________________________________________
__________________________
Signature – Parent or Legal Guardian
Date
HEARING
DATE
SIGNATURE
Hz
1000
2000
4000
PASS
R
FAIL
L
VISION
DATE
SIGNATURE
R20/_________________ L20/ _________________
PASS
FAIL
NOTE: If medical diagnosis and treatment and / or immunization and TB testing conflict with your religious beliefs, you must sign an
affidavit to that effect and attach it to this form. If immunization and / or TB testing would be injurious to your child or family, you must obtain a
certificate (signed by a health care professional) to that effect and attach it to this form.
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business