MARYLAND STATE DEPARTMENT OF EDUCATION
Office of Child Care
Medical Evaluation for Child Care
OCC 1204 – REVISED 02/2023 (All previous editions are obsolete)
A. Name of the Person Evaluated (please print): ___________________________________________ DOB: _______________
B. Name of Child Care Provider/Program: _____________________________________________________________________
AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION
I HEREBY AUTHORIZE THE RELEASE OF MEDICAL INFORMATION CONTAINED IN THIS REPORT TO THE OFFICE OF CHILD CARE.
Signature of the person being evaluated (guardian if a minor)
Date
This Section Must be Completed by a Physician or Registered Physician Assistant or Certified Registered Nurse Practitioner
1. DATE OF MEDICAL EVALUATION: ________________________
2. TUBERCULOSIS SCREENING:
Risks and Symptoms screening completed (required): ☐ Yes
TB Test: if indicated or required by the Local Health Officer
Type of Test: ___________________________ Date: ____________ Results: ____________________________
This individual is free of communicable tuberculosis. ☐ Yes ☐ No
3. IMMUNIZATIONS: I have discussed the importance of age-appropriate immunizations with this individual. ☐ Yes ☐ No
4. RECOMMENDATIONS:
The above individual is medically and emotionally fit to work, volunteer, or reside in a child care program. ☐ Yes ☐ No
If “No”, please provide a summary of medical/emotional problems or conditions or medications which may affect the
individual’s ability to work, volunteer or reside in a child care program. __________________________________________
____________________________________________________________________________________________________
5. For individuals working or volunteering in a child care program:
The individual meets the strength and mobility challenges required for caring for a child in one or more of the age
groups checked below:
0-2 years of age 2-6 years of age 7-12 years of age 12-18 years of age
6. Signature of the Health Care Provider/Designee: _____________________________________Date: ___________________
Printed Name and Credentials: _____________________________________________________________________________
STAMP or Complete Address and Telephone Number of the Health Care Provider:
