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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

 

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Date of Exam

 

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(Last)

 

 

 

(First)

 

(Middle)

SEX

DATE

 

DATE OF BIRTH

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

F

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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(No.)

 

 

(Street)

 

(City/Boro)

(State)

 

 

(Zip)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TELEPHONE:

 

 

 

 

 

 

 

 

 

 

JOB TITLE

 

 

AREA EMPLOYED

 

 

 

 

AC (

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PAST MEDICAL HISTORY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Please check YES or NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

NO

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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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:

 

 

 

 

 

 

 

Had a positive reaction to a PPD/Mantoux test or history of TB.

 

DATE:

 

 

 

 

 

History of BCG vaccine does not exempt a staff member from TB screening.

 

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

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.

 

 

 

 

 

 

 

 

(Of Supervisor if NP or PA)

 

Address:

 

 

 

Date of Exam

 

 

 

 

 

 

 

 

 

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

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.
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