The New York Daycare Annual Staff form is a critical document that ensures the health and safety of both staff and children in daycare settings. This form requires a health examination for all teaching and non-teaching staff, including volunteers and students, every two years. To maintain compliance and ensure a safe environment, fill out the form by clicking the button below.
In New York City, ensuring the health and safety of children in daycare settings is a top priority, and the New York Daycare Annual Staff form plays a crucial role in this effort. This comprehensive document is designed for all teaching and non-teaching staff members, including volunteers and students who regularly interact with children. Every staff member is required to undergo a health examination at the time of employment and every two years thereafter. The form collects essential information such as personal details, medical history, and immunization records. Staff members must disclose any past medical conditions, medications, or therapies that could impact their ability to provide care. Additionally, the form includes sections for tuberculosis testing and tobacco use, emphasizing the importance of maintaining a healthy environment. A medical provider must complete the physical exam section, noting any abnormal findings and confirming the staff member's fitness to care for children. Confidentiality is paramount; staff health records must be securely stored and maintained in compliance with New York City Health Code regulations. Overall, this form is a vital tool in promoting the well-being of both staff and children in daycare facilities.
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
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
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:
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.
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:
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)
RESULTS
DIAGNOSIS/PROBLEM
PLAN/FOLLOW-UP (For each diagnosis)
1.
2.
3.
4.
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:
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)
Completing the New York Daycare Annual Staff form is essential for ensuring that all staff members meet health requirements for working with children. Follow these steps carefully to fill out the form accurately.
After completing the form, it should be submitted to the appropriate authority at the daycare center. Ensure that all information is accurate and all necessary documentation is attached. This step is vital for maintaining compliance with health regulations in childcare settings.
The New York Daycare Annual Staff form is designed to ensure that all teaching and non-teaching staff members, including volunteers and students, undergo a health examination at the time of initial employment and every two years thereafter. This process helps to maintain a safe environment for children in daycare settings by assessing the health status of those who interact with them regularly.
All staff members, both teaching and non-teaching, are required to complete the form. This includes volunteers and students who have regular contact with children. It is essential for ensuring that everyone involved in childcare meets health standards.
Staff members must indicate whether they have a history of certain medical conditions, such as:
For any positive findings, staff members must provide explanations, including information on chronic medications or therapies they may be undergoing.
Staff members must provide evidence of immunity to specific diseases through documented vaccines, blood tests, or a provider-documented history of illness. The required immunizations include:
For measles, mumps, and varicella, two doses of the vaccine are required, with at least 28 days between doses.
The completed form, along with any additional health documentation, must be kept confidential and separate from other records at the daycare center. Records of required medical examinations should be maintained for as long as the staff member is employed and must be returned upon request when employment ends. In cases where chest x-rays are required, those reports should also be retained for the duration of employment and for two years thereafter.
If a staff member tests positive for tuberculosis (TB), they must undergo further evaluation, including a chest X-ray and possibly treatment. A report of the chest X-ray is required if the individual had a previous negative PPD/Mantoux test. It is important to follow these procedures to ensure the safety of both staff and children in the daycare environment.
Incomplete Personal Information: Many individuals neglect to fill out all sections related to their personal details, such as the full name, date of birth, and contact information. This omission can lead to delays in processing the form.
Failure to Provide Medical History: Some applicants mistakenly skip the section on past medical history. This section is crucial for understanding any potential health issues that could affect their ability to care for children.
Missing Immunization Records: Staff members often forget to attach their immunization records. Without this documentation, compliance with health regulations cannot be verified, which may hinder employment.
Inaccurate or Incomplete Tuberculin Testing Information: Individuals may not provide accurate dates or results for tuberculin testing. This can lead to confusion regarding their TB status and necessary follow-up actions.
Neglecting to Sign the Form: Some applicants overlook the importance of signing the form. A signature is necessary to validate the information provided and confirm that the applicant understands their responsibilities.
Not Keeping Copies of the Form: Lastly, individuals often fail to keep a personal copy of the completed form. Retaining a copy is essential for future reference and for ensuring that they have a record of their submissions.
In addition to the New York Daycare Annual Staff form, several other documents play a crucial role in ensuring compliance and maintaining a safe environment for children. Each of these forms serves specific purposes that contribute to the overall health and safety standards required in daycare settings. Below is a list of commonly used documents alongside a brief description of each.
Maintaining accurate and up-to-date records is essential for compliance with health regulations and for fostering a safe and healthy environment in daycare facilities. Each of these documents plays a significant role in supporting the overall well-being of both staff and children.
The New York Daycare Annual Staff form shares similarities with the Employee Health Assessment form commonly used in various workplaces. Both documents require staff members to undergo health examinations to ensure they are fit for their roles. They include sections for personal information, medical history, and a physical examination. The emphasis on confidentiality and the maintenance of health records is also a common thread, ensuring that sensitive information remains protected throughout the employment period.
Another document that resembles the New York Daycare Annual Staff form is the Child Care Staff Immunization Record. This form focuses specifically on the immunization status of staff members, requiring documentation of vaccinations and evidence of immunity to specific diseases. Like the daycare staff form, it mandates that records be kept confidential and updated regularly to comply with health regulations. Both documents serve to protect the health of children in care by ensuring that staff are not only healthy but also immune to communicable diseases.
The School Health Record is also similar in nature, as it is used to track the health status of teachers and staff within educational institutions. This document includes sections for medical history, physical examinations, and immunization records. Both forms emphasize the importance of regular health checks and maintain a focus on the staff's ability to provide a safe environment for children. The requirement for confidentiality and secure record-keeping is a critical aspect shared between these two forms.
The Occupational Health Questionnaire is another comparable document, often utilized in various industries to assess the health and fitness of employees. This questionnaire gathers information about past medical history, current health conditions, and any medications being taken. Similar to the daycare staff form, it aims to ensure that employees are capable of performing their job duties without health-related risks. Both forms require careful attention to detail in documenting health findings and maintaining confidentiality.
The Medical History Form used by many healthcare providers bears resemblance to the New York Daycare Annual Staff form. This document collects comprehensive medical history and current health status of individuals. It includes sections for past illnesses, medications, and any ongoing treatments. Both forms prioritize the health of individuals who work closely with vulnerable populations, such as children, and emphasize the importance of maintaining accurate and confidential health records.
Finally, the Health Screening Form used in various community programs is similar to the daycare staff form. This document assesses the health status of participants and includes sections for medical history, physical examinations, and health-related concerns. Both forms aim to identify any potential health issues that could affect the ability of staff to perform their duties effectively. Confidentiality is a key aspect in both cases, ensuring that personal health information is handled with care and respect.
When filling out the New York Daycare Annual Staff form, it’s important to be thorough and accurate. Here’s a list of things you should and shouldn’t do:
Misconceptions about the New York Daycare Annual Staff form can lead to confusion and compliance issues. Here are eight common misunderstandings:
Health Examination Requirement: All teaching and non-teaching staff members, including volunteers and students, must undergo a health examination upon initial employment and every two years thereafter.
Documentation: Attach any additional documents that support the information provided on the form. This could include medical records or other relevant paperwork.
Past Medical History: Be thorough when checking "YES" or "NO" for past medical conditions. If you check "YES," provide detailed explanations for any chronic medications or therapies.
Tuberculin Testing: While tuberculin testing is not required for employment, if positive, a chest X-ray and evaluation may be necessary.
Immunization Records: Ensure that all immunization records are documented. Staff must show evidence of immunity to specific diseases through vaccines, blood tests, or documented history of illness.
Confidentiality: Staff health records are confidential and must be stored separately from other records. This ensures privacy and compliance with regulations.
Record Retention: Keep records of medical examinations on file for as long as staff members are employed, and for two years after their employment ends.
Provider’s Assessment: The medical provider must assess the staff member's fitness for child care. This assessment should be documented clearly on the form.
Signature Requirement: Both the provider and the staff member must sign the form. This confirms that the information provided is accurate and complete.