The Kansas CCL 029 form is a crucial document required by the Kansas Department of Health and Environment for all children in licensed child care facilities. This form collects essential medical information, including immunization history and health assessments, ensuring that every child receives appropriate care while in a child care setting. Completing this form accurately is vital for the health and safety of your child; you can begin the process by clicking the button below.
The Kansas CCL 029 form is a crucial document designed for the health and safety of children in licensed child care facilities. It serves multiple purposes, primarily focusing on the medical records and immunization history of each child, including those of the provider’s own children. Parents or guardians are required to complete this form, which includes essential information such as the child’s name, date of birth, and contact details for parents or guardians. Additionally, the form captures the child's health history, allergies, and any special instructions that caregivers should be aware of. It also outlines the necessary immunizations, allowing for the transfer of medical records if a child moves to a different facility. Furthermore, the form includes a section for a Child Health Assessment, which must be completed by a licensed physician or an approved nurse, ensuring that each child’s health is routinely monitored. This comprehensive approach not only facilitates communication between parents and caregivers but also adheres to state regulations, thereby promoting a safe and healthy environment for children in care.
CCL. 029
Kansas Department of Health and Environment
Rev. 8/2011
Bureau of Child Care and Health Facilities
Child Care Licensing Program
1000 SW Jackson, Suite 200
Topeka, KS 66612-1274
Phone (785) 296-1270 Fax (785) 296-0803
Website: www.kdheks.gov/kidsnet
MEDI CAL RECORD FOR ALL CHI LDREN I N CHI LD CARE FACI LI TI ES,
I NCLUDI NG PROVI DER’S OWN CHI LDREN
Parents are to complete the Medical Record and the History of I mmunizations for each child in licensed child care facilities. The Medical Record, History of I mmunizations, and Child Health Assessment are transferable w hen the child moves to another licensed child care facility.
Child’s First Day in Child Care
Name of Child Care Facilit y
Child’s Name
Date of Birth
Gender
First
Last
MM/ DD/ YYYY
M/ F
Parent/ Guardian I nformation
Name
Home Address
Street
City
Zip Code
Home Phone Number
Work Address
Work Phone Number
Cell Phone Number
E-mail Address
Best way to contact
Names and ages of children in family
Persons aut horized to pick up the child or to notify in case of emergency. I nclude name, address, and telephone number. Attach an additional page, if necessary.
Child’s Physician
Phone Number
Child’s Dentist
Hospital Preference (for emergencies)
Has your physician approved the use of any non-prescription medications for your child such as acetaminophen, cough
syrup, 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) ? I f yes, provide information on Aut horization for Emergency Medical Care form CCL. 010.
Allergies
Frequent sore throats/ colds
Ear Aches
Asthma
Speech, Visual, Hearing
Diabetes
Epilepsy/ Seizures
Other
I f yes answered to any above, please provide additional information
Have 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 t he person caring for your child.
Parent/ Guardian Signature:____ ____________ ___________________ ______ Date:_________ ____
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History of I mmunizations
Required for all children in child care facilities, including the provider’s ow n children. A Kansas Certificate of I mmunizations ( KCI ) may be substituted for this form and attached to the completed Medical Record.
Child’s Name:
Date of Birth:
Section I . For a recommended schedule of immunizations, refer to the current schedule published by the Advisory Committee on I mmunization Practices ( ACI P) .
Vaccine
Record the Month. Day and Year that each Dose of Vaccine w as Received
1 st
2 nd
3 rd
4 th
5 th
6 th
DTaP/ DT/ Td/ Tdap (Diphtheria,
Tetanus, Pertussis)
Polio
MMR (Measles, Mumps, and Rubella
combined)
HBV (Hepatitis B Vaccine)
Hx of Disease:
Date of I llness:
Varicella (Chicken Pox)
Physician Signature
HI B (Hemophilus I nfluenzae Type B)
PCV7 (Pneumococcal Conjugate)
HEP A (Hepatitis A)
Rotavirus * * Recommended < 8 mo of
age; not required
I nfluenza( Flu) * * Recommended
annually > 6 mo of age; not required
Section I I .
Complete this section only if your child is exempted from the law requiring immunizations [ K.S.A. 65 - 508( d) ] .
Section I I . Complete Section below only if your child is exempted from law s requiring requiring
The following two options are the ONLY exemptions allowed by law. Please check either ( A) or ( B) below and immunizations [ K.S.A. 65 - 508( d) and K.S.A. 65 - 519( c) ]
complete as required:
( A) Certification from licensed physician stating that immunization w ould endanger child’s life:
Exempt from following immunizations:
DTP
Pertussis Only ____Tetanus ____Polio
MMR
Rubella Only
Hep A
Hep B
Hib
_PCV7 ____Ot her
Physician’s Signature (required): ________________________________________________Date:_______________
( B) My child is exempt under the law from immunizations. As the Parent or Legal Guardian, I state that I am an adherent of a religious denomination w hose teachings are opposed to immunizations.
Section I I I .
Parent/ Guardian Signature:____ ____________ ___________________ ______ Date:_________ _______
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CCL. 029a
Rev. 08/2011
Child Health Assessment
The Child Health Assessment form is to be completed and signed by a nurse approved by KDHE to perform Child Health Assessments or a Licensed Physician. I f a Physician Assistant (PA) completes the Child Health Assessment, t he signature of 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 all children including children of the provider or staff in Licensed Day Care Homes, Group Day Care Homes, Child Care Centers and Preschools. A Kan-Be-Healthy Assessment Form is a KDHE Form and is acceptable, a Physician Health Assessment 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_______ __ ___________________ _____________ Date of Birth_________ __________
Health history and medical information pertinent to routine child care and emergencies (describe, if any):
None
Do you see this child for regular health supervision:
Yes No
Allergies to food or medicine ( describe, if any):
List current medications (if any):
Length/ Height: ______ I N/ CM
% I LE_______
Weight: _____ LB/ KB % I LE_______
Physical Examination
I f Normal
I f Abnormal - Comments
Head/ Ears/ Eyes/ Nose/ Throat
Teeth
Cardio/ Respiratory
Abdomen/ GI
Genitalia/ Breasts
Extremities/ Joints/ Back/ Chest
Skin/ Lymph Nodes
Neurologic & Developmental
Screening Tests
Screening Date
Note Here if Results are Pending or Abnormal
Lead
Anemia (HGB/ HCT)
Urinalysis (UA)
Hearing
Vision
Health Problems or Special Needs, Recommended Treatment/ Medications/ Special Care (Attach additional sheets if necessary)
Signature of Licensed Physician or Nurse approved for Child Health Assessments
Date
Print the Name of the I ndividual Signing Above
Address
3
Filling out the Kansas CCL 029 form requires careful attention to detail. This form collects essential medical information for children in licensed child care facilities. After completing the form, submit it to the appropriate child care provider.
The Kansas CCL 029 form is a medical record required for all children in licensed child care facilities in Kansas. This includes children of the provider. The form collects essential health information, including medical history, immunization records, and emergency contact details. It ensures that caregivers have the necessary information to provide safe and appropriate care.
Parents or guardians of children attending licensed child care facilities must complete the CCL 029 form. This requirement applies to all children, including the provider's own children. The form must be filled out accurately to ensure that child care providers can respond effectively to any health issues that may arise.
The form requires several key pieces of information, including:
Completing all sections thoroughly is important for the child's safety and care.
Yes, the medical record, history of immunizations, and child health assessment are transferable when a child moves to another licensed child care facility. This ensures continuity of care and helps the new provider understand the child's health needs.
If your child has special health needs or medical conditions, it is crucial to provide detailed information on the CCL 029 form. This includes allergies, chronic conditions, and any medications your child is taking. Additionally, you can attach further information if necessary. Clear communication about your child's health will help caregivers provide the best possible care.
If your child is exempt from immunizations, you must complete the exemption section on the CCL 029 form. There are two options for exemptions: a medical exemption certified by a licensed physician or a religious exemption. Make sure to provide the required signatures and documentation to ensure compliance with state regulations.
Failing to provide accurate contact information for parents or guardians. Ensure that all phone numbers and addresses are correct.
Not including the child’s full name and date of birth. Both are essential for proper identification.
Leaving out the medical history section. This information is crucial for the child’s care and safety.
Forgetting to list any allergies or medical conditions. This could lead to serious health risks while in care.
Not signing and dating the form. A signature is required to validate the information provided.
Overlooking the immunization records. Ensure that all vaccinations are documented properly.
Failing to indicate the preferred hospital for emergencies. This helps caregivers act quickly in critical situations.
Not providing names and contact details for authorized pick-up persons. This is important for child safety.
Neglecting to attach additional pages if necessary. Use extra sheets for any required details that don’t fit on the form.
The Kansas CCL 029 form is essential for documenting the medical history and immunization records of children in licensed child care facilities. Along with this form, several other documents are commonly utilized to ensure the health and safety of children in care. Below is a list of these related forms and documents, each serving a specific purpose in the child care licensing process.
These documents work together to ensure that children receive appropriate care and that child care facilities comply with state regulations. Keeping accurate records not only protects the health of the children but also helps providers maintain a safe and nurturing environment.
The Kansas CCL 029 form is similar to the Child Health Assessment form, which is also essential for children in licensed child care settings. This document requires completion by a nurse or licensed physician and provides a comprehensive overview of a child's health status. The Child Health Assessment includes sections for medical history, allergies, and current medications, much like the CCL 029 form. Both documents ensure that caregivers have the necessary health information to provide appropriate care and respond effectively in emergencies.
Another document akin to the Kansas CCL 029 is the Kansas Certificate of Immunizations (KCI). This form serves as an official record of a child's immunizations, which can be submitted in lieu of the immunization section on the CCL 029. The KCI is critical for verifying that a child has received the necessary vaccinations before entering a child care facility. Both forms facilitate the transfer of immunization records when a child moves to a new facility, thereby ensuring continuity of care.
The Authorization for Emergency Medical Care form (CCL 010) shares similarities with the CCL 029 by addressing emergency situations. This form allows parents to provide consent for emergency medical treatment for their child, should the need arise. While the CCL 029 gathers general health information, the CCL 010 focuses specifically on emergency care, ensuring that caregivers can act quickly and appropriately in critical situations.
Additionally, the Kan-Be-Healthy Assessment Form aligns closely with the CCL 029. This KDHE form is designed for children and is part of the health assessment process required for licensed child care facilities. Both forms collect vital health information and are used to ensure that children receive appropriate health supervision. The Kan-Be-Healthy Assessment, like the CCL 029, is transferable and can be attached to other health records when a child changes care providers.
The School Health Assessment Form is another document that resembles the Kansas CCL 029. This form is specifically tailored for school-age children and includes health information pertinent to their well-being in an educational setting. While the CCL 029 is focused on child care, both documents serve the purpose of documenting health histories and ensuring that children receive necessary medical attention. They also both facilitate communication between parents and caregivers regarding a child's health needs.
Finally, the Parent/Guardian Consent Form for Medication Administration is similar to the Kansas CCL 029 in that it allows parents to authorize caregivers to administer medications to their children. This form outlines the specifics of what medications can be given and under what circumstances. Both forms emphasize the importance of clear communication between parents and child care providers regarding a child's health and medication needs, ensuring that all parties are informed and prepared to act in the best interest of the child.
When filling out the Kansas CCL 029 form, it is important to follow specific guidelines to ensure accuracy and compliance. Here is a list of things you should and shouldn't do:
Here are six common misconceptions about the Kansas CCL 029 form, which is essential for child care facilities:
Understanding these misconceptions can help parents and guardians navigate the requirements more effectively, ensuring that children receive the care they need.
When filling out and using the Kansas CCL 029 form, several important considerations can help ensure accuracy and compliance. Here are key takeaways to keep in mind:
By following these guidelines, you can ensure that the Kansas CCL 029 form is filled out correctly, facilitating a smooth experience for both parents and child care providers.