Successful Foster Home Licensing in NC - Training Matters

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Foster Home / Residential Child Care Medical History Form Name: ______________________________________________________________________ Home Address: _______________________________________________________________ Phone: ___________________________________ Birth date: __________________________ Health History Any history, past, or present of: Yes No Head or back injuries _____ _____ Neurological disorders, convulsions, etc. _____ _____ Heart disease, high blood pressure, or rheumatic fever _____ _____ Lung disorders, asthma, tuberculosis _____ _____ Stomach, gall bladder, or other gastro-intestinal disorders _____ _____ Allergies to food, drug, plant, etc. _____ _____ Blood disorders, anemia, leukemia, etc. _____ _____ Kidney trouble _____ _____ Venereal disease _____ _____ Diabetes or other glandular disorders _____ _____ Surgery _____ _____ Reproductive system problems _____ _____ Psychological disorders, mental health illness _____ _____ Physical disabilities _____ _____ Other chronic illnesses, diseases, or disorders _____ _____ If any of the above questions were answered yes, please elaborate: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ What do you consider your state of health: Excellent _____ Fair _____ Good _____ Poor _____ To the best of my knowledge, the above information is correct. _______________________________________ Signature DSS-5017 (Rev. 09/28/09) North Carolina Division of Social Services Family Support and Child Welfare Services ________________ Date
NORTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES DIVISION OF SOCIAL SERVICES (Name of Agency Requesting Information) In order to protect the agency/facility and the children who may reside in the family foster home or residential child care facility, the agency must obtain medical information on the person whose name appears below in order to be in compliance with licensure rules. The person named below has given the agency permission to obtain their medical report and to the release of information by the licensed medical provider, also named below. I, , agree to the release of pertinent information by the licensed medical provider, . Date: ______________________________________________________________________________ Name Age Address Height Weight Blood Pressure Pulse History of Illnesses: Yes No Yes No Tuberculosis or other Fainting and dizzy spells pulmonary defects Venereal disease Heart Trouble Seizures Serious defects of bones and joints Mental or emotional disturbance Other chronic or communicable diseases Hypertension Specify if yes: Physical Examination (Circle all that were examined.) Heart Lungs Abdomen Genitalia ENT Extremities Hernia Eyes Date of examination: Date of tuberculin skin test: Result: Positive Negative Date of chest X-ray*: Findings: *(Required only if tuberculin test positive) Please comment on any physical, mental or emotional condition or communicable/infectious disease apparent from your examination or any knowledge of the above-named person that might affect the health, safety or welfare of children residing in the home of facility: Physician’s, PA’s or NP’s Signature: Address: Date: Phone: DSS-5156 (9-1-02) Children’s Services
Page 1 and 2: Handouts for the Webinar Successful
Page 3 and 4: Tips for Using the DSS-5015 Submit
Page 5 and 6: Tips for Using the Other Licensing
Page 7 and 8: FOSTER HOME RELICENSE, TERMINATION
Page 9 and 10: III. LICENSE CHANGE REQUEST III. Li
Page 11 and 12: FAMILY FOSTER HOME RELICENSURE, TER
Page 13: Foster Home Environmental Condition
Page 17 and 18: 2 V. Day Care Center Operation If t
Page 19 and 20: 4 understanding of the importance o
Page 21 and 22: Child Central Registry Check from a
Page 23 and 24: (19) assumes responsibility for her
Page 25 and 26: administration of a physical restra
Page 27 and 28: (5) Separate and accessible drawer
Page 29 and 30: Present Employment: Phone Number: I
Page 31 and 32: Skill 12: Making an informed decisi
Page 33 and 34: SIGNATURES I have reviewed and am i
Page 35 and 36: B. RACE CODES Race codes and possib
Page 37 and 38: June 15, 2010 Webinar Successful Fo
Page 39 and 40: June 15, 2010 Webinar DSS-5015 (con
Page 41 and 42: June 15, 2010 Webinar Perfect New A
Page 43 and 44: Follow-up Document from the Webinar
Page 45 and 46: If adding a new adult to the househ
Page 47 and 48: At initial licensure, are children
Page 49 and 50: A home cannot be licensed for TFC i
Page 51 and 52: Should we be asking how serious a d

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