➨

Fillable New York Daycare Annual Staff Form in PDF

The New York Daycare Annual Staff form is a crucial document used by daycare centers to ensure the health and safety of children in their care. This form requires a health examination for all staff members, including volunteers and students, at the time of initial employment and every two years thereafter. Proper completion and maintenance of this form help maintain compliance with health regulations set forth by the New York City Department of Health and Mental Hygiene.

Access This Form Online

Access This Form Online

Article Guide

The New York Daycare Annual Staff form is an essential document designed to ensure the health and well-being of both staff and children in daycare settings. This form is required for all teaching and non-teaching staff members, including volunteers and students who regularly interact with children. It mandates a health examination upon initial employment and every two years thereafter. The form collects vital information such as the staff member's name, date of birth, job title, and past medical history. Staff members must disclose any chronic conditions, medications, or therapies that may impact their ability to care for children. Additionally, the form includes sections for physical examination results, tobacco use, and immunization records, which are crucial for preventing the spread of infectious diseases. Tuberculin testing is also addressed, with specific guidelines for those who may have a history of positive reactions or BCG vaccinations. Confidentiality is a key aspect, as health records must be kept separate from other records and returned to staff upon termination of employment. Overall, this form plays a critical role in maintaining a safe and healthy environment in New York's daycare facilities.

Preview - New York Daycare Annual Staff Form

Agency Stamp

NEW YORK CITY DEPARTMENT OF HEALTH AND MENTAL HYGIENE

BUREAU OF CHILD CARE

STAFF HEALTH FORM

Initial employment and every 2 years, a health examination is required for all teaching and non-teaching staff members, including volunteers and students who regularly associate with children. Attach any additional documentation to this form.

Date of Employment

Date of Exam

(Last)

(First)

(Middle)

SEX

DATE

DATE OF BIRTH

F ☐

M ☐

(No.)

(Street)

(City/Boro)

(State)

(Zip)

TELEPHONE:

JOB TITLE

AREA EMPLOYED

AC (

)

PAST MEDICAL HISTORY

Please check YES or NO

YES

Please explain any positive findings, list and explain any chronic

medications or therapies:

☐

Hypertension

☐

Heart Disease

☐

Diabetes

☐

Seizure Disorder

☐

Chronic Lung Disease

☐

Mental Illness

☐

Alcohol Abuse

☐

Substance Abuse

☐

Physical Disabilities

☐

Allergies

☐

Hepatitis

☐

OTHER (SPECIFY)

MEDICAL PROVIDER SECTION

PHYSICAL EXAM: (Please note any conditions or findings considered abnormal or requiring medical follow-up)

Height

Weight

Blood Pressure

TOBACCO USE

☐ Current

☐ Former

☐ None

If current, referred for cessation services?

☐ Yes

☐ No

Counselled re: No Smoking

☐ Yes

☐ No

7K rev1_11_2017.indd

Staff Name _________________________________________ D.O.B._________/_________/_________

TUBERCULIN TESTING (Not required for employment)

DATE TESTED:

TUBERCULIN SKIN TEST: PPD MANTOUX (5 TU)

OR	DATE INTERPRETED:
BLOOD TEST: QUANTEFERON GOLD
Staff exempt from testing if they	RESULTS:
Staff exempt from testing if they
Had a positive reaction to a PPD/Mantoux test or history of TB.		DATE:
		DATE:
History of BCG vaccine does not exempt a staff member from TB screening.		DATE:
		DATE:

All positive tuberculin tests in persons whose previous PPD/Mantoux was negative, require a chest X-ray and evaluation if treatment is indicated. All positive tuberculin tests (PPD Mantoux 10 mm or over) require a report of one chest X-ray, (H.C. 49.06).


CHEST X-RAY:	DONE AT:	TREATMENT:
DATE:	RESULTS:

IMMUNIZATION RECORD

Staff are required to have evidence of immunity to the diseases below through either documented vaccines, blood test documenting immunity, or provider-documented history of illness (except where shaded in grey). Records should be kept in the staff person’s file.

Documentation of	Vaccine Name	Vaccine Date 1	Vaccine Date 2		Blood Test Documenting	Provider-Documented History
Immunity	Vaccine Name	Vaccine Date 1	Vaccine Date 2		Immunity (Yes / No)	of Illness (Yes / No)

Tdap (Tetanus-
diphtheria-acellular
pertussis)

Rubella

Measles*

Mumps*

Varicella*

*Two doses of vaccine are required at least 28 days apart



LABORATORY TESTS (Optional) (Specify tests ordered)					DATE	RESULTS





DIAGNOSIS/PROBLEM				PLAN/FOLLOW-UP (For each diagnosis)

1.				1.

2.				2.

3.				3.

4.				4.

5.				5.

On the basis of my findings as indicated above and my knowledge of the staff member, I find that the above person is fit to give adequate child care to children in a day care setting at this time.

Provider’s Name (Print)	License No.	Telephone No.
Provider’s Name (Print)	License No.	Telephone No.
	(Of Supervisor if NP or PA)
Address:	Date of Exam
Address:	Date of Exam
Provider’s Signature	Staff Signature
Provider’s Signature	Staff Signature

NOTE TO THE DAY CARE CENTER: Staff Health Records are confidential and must be kept separate from all other records. Records of required medical examinations must be kept on file at the day care center as long as staff members are employed. They must be returned to them upon their request when their employment is terminated. In cases where chest x-rays are required, x-ray reports must be kept on file at the day care center as long as the person is employed and two years thereafter.

(New York City Health Code Section 45.09)

7K rev1_11_2017.indd

Get New York Daycare Annual Staff PDF Form

Form Characteristics

Fact Name	Description
Governing Authority	The form is governed by the New York City Department of Health and Mental Hygiene.
Health Examination Requirement	All teaching and non-teaching staff, including volunteers and students, must undergo a health examination upon initial employment and every two years thereafter.
Tuberculin Testing	Tuberculin testing is not required for employment, but positive results necessitate a chest X-ray and evaluation.
Immunization Records	Staff must provide evidence of immunity to certain diseases through vaccinations, blood tests, or documented history of illness.
Confidentiality of Records	Staff health records are confidential and must be kept separate from other records at the daycare center.
Retention of Records	Medical examination records must be retained for the duration of employment and for two years after termination.

Please rate Fillable New York Daycare Annual Staff Form in PDF Form

4.86

Perfect

22 Votes

More PDF Templates

Nyc Op 98 - Requires specific identification of the systems tested, including water/sanitary, storm, and sprinkler components.

Gas Stove Installation Rules Nyc - Reiterates the serious legal implications of falsifying information on the application, promoting honesty and integrity.

Ga-4 Form - The classification of falsifying the GA-4 form as a class E felony underlines the serious legal implications of misreporting.