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The Health Screening Report form is a vital document within California's regulatory framework for facilities serving vulnerable populations, including the elderly, children, and individuals with developmental disabilities. This form ensures that all personnel associated with Residential Care Facilities for the Elderly and Community Care or Child Care Facilities meet the necessary health standards to effectively perform their roles. Specifically, it mandates a health appraisal conducted by a physician to confirm that employees are free from communicable diseases and are capable of fulfilling their job responsibilities. The timing of the health screening is critical; it must be completed within one year prior to employment or within a week after starting work. The form not only includes personal information regarding the individual, such as name, age, and position title but also outlines details about the facility and the specific population served. Moreover, it incorporates an authorization section that allows for the release of medical information, emphasizing the importance of communication between medical professionals and facility operators. The physician's evaluation is paramount, as it addresses the general health of the individual and their ability to perform the duties outlined in the duty statement, highlighting any health conditions that may pose risks to themselves or others. Through this comprehensive approach, the Health Screening Report plays a crucial role in safeguarding the health and well-being of both employees and the populations they serve.

Health Screening Report Example

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

 

COMMUNITY CARE LICENSING DIVISION

HEALTH SCREENING REPORT - FACILITY PERSONNEL

All personnel, including applicant, licensee or employed staff of Residential Care Facilities for the Elderly, Community Care or Child Care Facilities must demonstrate that their health condition allows them to perform the type of work required. This health appraisal is to be completed by or under the direction of a physician.

A health screening, by or under the direction of a physician must have been performed not more than one year prior to employment or within seven (7) days after employment.

FACILITY NAME

FACILITY ADDRESS

PERSON'S NAME

AGE

POSITION TITLE

TYPE OF FACILITY

WORK DAYS PER WEEK

WORK HOURS PER DAY

DUTY STATEMENT

TYPES OF PERSONS SERVED (Check appropriate items)

Infants

Adults

Children

Elderly

Developmentally Disabled

Mentally Disordered

Physically Handicapped

Drug/Alcohol Addiction

Other (specify) ______________________________________________________________________________________________

AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION

I HEREBY AUTHORIZE THE RELEASE OF MEDICAL INFORMATION CONTAINED IN THIS REPORT.

SIGNATURE OF APPLICANT/LICENSEE OR EMPLOYEE

ADDRESS

DATE

NOTE TO PHYSICIAN: Personnel in Residential Care Facilities for the Elderly, Community Care or Child Care Facilities shall be free from communicable disease, and capable of performing assigned tasks. Please complete the following information on the above named person.

EVALUATION OF GENERAL HEALTH

EVALUATION OF ABILITY TO PERFORM WORK DESCRIBED IN THE ABOVE DUTY STATEMENT

NOTE ANY HEALTH CONDITION THAT WOULD CREATE A HAZARD TO THE PERSON, CLIENTS, CHILDREN OR OTHER PERSONNEL

 

DATE OF T.B. TEST

POSITIVE

ACTION TAKEN (IF POSITIVE)

 

 

 

 

 

 

 

 

 

 

 

NEGATIVE

 

 

 

 

 

DATE OF HEALTH SCREENING

 

NAME OF PHYSICIAN (PHYSICIAN’S STAMP)

 

DATE

 

 

 

 

 

 

 

 

 

 

HEALTH SCREENING BY: (ORIGINAL SIGNATURE)

TELEPHONE #

DATE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LIC 503 (3/99) (PERSONAL)

Form Characteristics

Fact Name Fact Description
Governing Law The Health Screening Report for personnel in California is governed by regulations from the California Department of Social Services, particularly focusing on the licensing of community care and child care facilities.
Eligibility Requirements All employees, applicants, and licensees in residential care facilities must undergo a health screening to ensure they can perform their job duties safely.
Timeframe for Screening A health screening must be completed no more than one year before employment or within seven days after starting work.
Authorization Applicants and licensees must authorize the release of their medical information as part of the screening process.
Health Assessment The screening consists of evaluating general health, ability to perform specific job duties, and identifying any health conditions that may pose a risk to clients or other staff.
T.B. Test Requirement A tuberculosis test is a critical part of the screening, requiring documentation of the test result and any actions taken if the result is positive.
Types of Persons Served Facilities are required to indicate the types of individuals they serve—this includes infants, children, adults, the elderly, and those with disabilities or substance abuse issues.
Physician's Role Health screenings must be conducted by a physician or under their direction to ensure professional oversight and accuracy.
Documentation Completed health screening reports must include the physician's stamp, signature, and date to validate the assessment.

Guidelines on Utilizing Health Screening Report

Completing the Health Screening Report form is essential for ensuring that facility personnel meet health standards required for their roles. After filling out the form accurately, it will be submitted to the appropriate authority as part of the employment verification process. Following are the steps to fill out the form correctly.

  1. Facility Information: Write the name and address of the facility at the top of the form.
  2. Personal Details: Fill in the person's name, age, and position title.
  3. Type of Facility: Indicate the type of facility by checking the appropriate box.
  4. Work Schedule: Specify the number of workdays per week and the hours worked per day.
  5. Duty Statement: Provide a brief description of the person's duties.
  6. Types of Persons Served: Check all applicable types of persons served such as infants, adults, or elderly, and specify any other categories.
  7. Authorization: The applicant or licensee must sign the authorization for the release of medical information and provide their address and date.
  8. Evaluation Section: Physicians must complete the evaluation of general health, ability to perform work, and note any health conditions that may pose a hazard.
  9. T.B. Test Information: Record the date of the T.B. test and indicate whether it was positive or negative.
  10. Health Screening Details: Enter the date of the health screening, and have the physician sign and stamp the form.
  11. Contact Information: The physician must provide their telephone number next to their signature.

What You Should Know About This Form

What is the purpose of the Health Screening Report form?

The Health Screening Report form ensures that all personnel working in residential care facilities, community care facilities, or child care facilities meet health standards necessary for their positions. It confirms that employees do not have any communicable diseases and are physically capable of performing their assigned tasks.

Who needs to complete the Health Screening Report form?

All personnel, including applicants, licensees, and employed staff, must fill out the Health Screening Report form. This requirement applies to anyone working in Residential Care Facilities for the Elderly, Community Care, or Child Care Facilities.

How often must the health screening be conducted?

A health screening, conducted by a physician or under their direction, must be completed within one year prior to employment or within seven days after employment. Staying current with your health screening is crucial for compliance.

What information is collected in the Health Screening Report?

The form collects essential details such as the individual's name, age, position title, and type of facility they work in. It also requests evaluations of general health and the ability to perform assigned duties. Additionally, the physician must note any health conditions that could pose a risk to clients or coworkers.

What should I do if my TB test is positive?

If a TB test result is positive, the physician must document the action taken in the report. This may involve follow-up testing or treatment. It's essential to discuss any necessary precautions and clearance required to work in the facility.

Where do I submit the completed Health Screening Report form?

The completed form should be submitted to the facility’s designated administrative office. Ensure that all required signatures and physician’s evaluations are completed before submission to maintain compliance.

What happens if I do not complete the Health Screening Report on time?

Failure to complete the Health Screening Report within the specified timeframe could result in delays in employment or continued work in the facility. It is crucial to adhere to the deadlines to avoid any disruptions in your role or licensed status.

Common mistakes

When filling out the Health Screening Report form, one common mistake is neglecting to ensure that the health appraisal is conducted within the appropriate time frame. Applicants must have a health screening performed either within the year before employment or within seven days after starting work. Missing this deadline may lead to delays in the hiring process and could impact the ability to work in sensitive environments, such as health or childcare facilities.

Another frequent error involves incomplete or inaccurate information about the individual’s current health status. The form requires a comprehensive evaluation of a person's health, including any existing conditions that might affect their ability to perform job duties safely. Omitting details or providing misleading information can have serious implications not only for the individual but also for the safety and well-being of the clients and coworkers.

People often overlook the significance of the authorization for the release of medical information. This section should be carefully completed to ensure that authorized personnel can access necessary medical details that may be relevant for employment. Failing to sign or provide needed information in this section could delay processing and hinder timely employment approval.

Lastly, many individuals mistakenly forget to include the physician’s stamp and signature. The form explicitly states that a physician must complete the health appraisal. Without proper verification from a licensed medical professional, the report may be deemed incomplete or invalid, further complicating the hiring process. It’s essential to double-check that all required sections are filled out completely before submission.

Documents used along the form

The Health Screening Report form serves as a crucial document for ensuring that personnel in care facilities are fit for their roles. Alongside this form, several other documents are commonly used to establish a comprehensive overview of an individual’s qualifications and suitability for employment. Below is a list of related forms and documents that typically accompany the Health Screening Report form.

  • Employment Application: This document collects essential information about the applicant’s background, work history, and qualifications relevant to the position. It is typically the first step in the hiring process.
  • Criminal Background Check Consent Form: This form gives authorization for a background check to be conducted. It helps employers ensure the safety of clients by verifying the applicant's criminal history.
  • References Form: Applicants provide contact information for previous supervisors or colleagues who can attest to their work ethic and character. This document helps employers gain insight into the applicant's capabilities from external sources.
  • Physician's Verification Form: This form is often completed after the Health Screening Report and serves as an additional verification from the physician regarding the applicant's health status and ability to perform their job duties safely.
  • TB Test Result Form: This document specifically records the results of the tuberculosis test. It is crucial for ensuring that personnel do not pose a risk of spreading communicable diseases in the facility.
  • Confidentiality Agreement: Personnel typically sign this agreement to acknowledge their commitment to maintaining the confidentiality of client information and facility operations, ensuring compliance with privacy regulations.
  • Emergency Contact Form: This form gathers emergency contact information for each employee. It is vital for ensuring staff well-being and effective communication during emergencies.

These supplementary documents collectively enhance the hiring process and the operational integrity of care facilities. They ensure that all personnel are evaluated thoroughly for their capability to provide safe and effective care.

Similar forms

The Health Screening Report is an essential document designed to ensure that personnel in care facilities are fit to perform their duties. Several other documents share similar purposes, focusing on health assessments and safety in various contexts. Here is a list of six documents that are comparable to the Health Screening Report, along with explanations of their similarities:

  • Employee Health Assessment Form: This document evaluates an employee's health status prior to their start date, ensuring they are physically fit for their job responsibilities. Just like the Health Screening Report, it may include information on communicable diseases and the ability to perform specific tasks.
  • Pre-Employment Medical Examination Report: Employers often require this report to verify a candidate's health before employment. Similar to the Health Screening Report, it includes assessments related to the person's ability to handle job duties safely and effectively.
  • Annual Health Check-Up Report: Many organizations mandate annual health check-ups to monitor employee health over time. Like the Health Screening Report, it ensures that personnel remain fit for their roles, promoting a safe working environment.
  • Workplace Injury Assessment Form: This document is completed when an employee is injured at work. It assesses the individual's condition and may recommend restrictions or changes to duties, akin to how the Health Screening Report evaluates potential risks related to health.
  • Child Care Provider Health Declaration: For those working in child care, this form requires individuals to affirm their health status and ability to care for children. It mirrors the Health Screening Report's focus on safety and health qualifications specific to vulnerable populations.
  • Occupational Health Clearance Certificate: Issued after a thorough health evaluation, this certificate confirms that an employee is cleared to work in their respective environment. Similar to the Health Screening Report, it emphasizes the need for health evaluations to mitigate risks in certain roles.

Each of these documents emphasizes the importance of health assessments to ensure that individuals are prepared to fulfill their duties while safeguarding the health and safety of those they serve.

Dos and Don'ts

When filling out the Health Screening Report form, it is essential to follow specific guidelines to ensure accuracy and compliance. Below are important dos and don'ts to keep in mind:

  • Do provide all required personal information accurately, including your name and position title.
  • Do ensure the health appraisal is completed by a qualified physician, as specified.
  • Do mention any relevant health conditions that could impact your ability to work.
  • Do sign and date the authorization for the release of medical information.
  • Don't omit any sections of the form; each part is important for your evaluation.
  • Don't submit the form without ensuring it was signed by a physician.
  • Don't provide incorrect information regarding the types of persons served.
  • Don't delay completing the health screening; it must be done within the established timeframes.

Misconceptions

There are many misconceptions about the Health Screening Report form. Here are ten common ones:

  1. Only new employees need to fill out the form. This form is required for all personnel, including current staff and licensees, to ensure ongoing health compliance.
  2. Any doctor can complete the health screening. The form must be completed by a physician or under their direction to ensure accurate health assessment.
  3. The health screening is only about physical health. It also takes into account the ability to perform specific job duties and any health conditions that might pose risks.
  4. A health screening is needed just once. While it must be updated annually, a new evaluation is also required if performed more than seven days after employment begins.
  5. The form is not important for clients or children. The health of all personnel, especially in care facilities, directly impacts the safety and well-being of all served individuals.
  6. The form does not require patient consent. The applicant must authorize the release of medical information as part of the process.
  7. Completing the form is the physician's responsibility. While physicians guide the health evaluation, the personnel must provide accurate information and participate in the process.
  8. Submitting the form is enough to guarantee safety. Regular reviews and updates are essential to maintaining a healthy workplace and ensuring all personnel remain fit for duty.
  9. Health screenings are only for specific facilities. Any facility caring for vulnerable populations, including elderly or developmentally disabled individuals, must adhere to this requirement.
  10. Results from the health screening are not confidential. The information on this form is protected; it can only be shared with authorized personnel.

Understanding these misconceptions can help ensure that all personnel maintain the required health standards and provide safe care.

Key takeaways

Filling out the Health Screening Report form is essential for ensuring that facility personnel can safely perform their duties. Here are key takeaways when using this form:

  • Timeliness is Crucial: Ensure that the health screening occurs no more than one year before employment or within seven days after starting work. This timing is essential for compliance.
  • Complete All Sections: Fill in all required information, including personal details, facility specifics, and types of persons served. Missing information can delay the process.
  • Physician Involvement is Mandatory: A physician must complete the examination and sign off on the findings. This verification is critical for the health and safety of all involved.
  • Health Hazards Must Be Noted: If there are any health conditions that may pose a risk to clients, children, or personnel, these must be clearly documented. Failure to report such conditions could have serious consequences.