State of Illinois Department of Children and Family Services Medical Report on an Adult in a Child Care Facility (CFS 602) Completed Form Examples and Samples

View a completed example of the Illinois DCFS Form CFS 602, the Medical Report on an Adult in a Child Care Facility. This detailed sample helps employees and facility operators correctly fill out the form, including physician's assessment and TB test results, for state compliance.
State of Illinois Department of Children and Family Services Medical Report on an Adult in a Child Care Facility (CFS 602) has a moderate Form Complexity Index of 61/100 — Instafill’s AI completes it in under a minute.
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A sample of a completed State of Illinois CFS 602 Medical Report on an Adult in a Child Care Facility.

CFS 602 Example: Medical Report for a Child Care Facility Adult

How this form was filled:

This example shows a completed CFS 602 form for a new employee at a child care facility. It includes the applicant's information, the physician's examination findings, a negative tuberculosis (TB) test result, and the physician's signed confirmation that the individual is medically fit to work with children.

Information used to fill out the document:

  • Applicant's Name: Olivia Chen
  • Applicant's Date of Birth: May 15, 1998
  • Applicant's Address: 456 Oak Ave, Springfield, IL 62704
  • Child Care Facility Name: Bright Beginnings Daycare
  • Child Care Facility Address: 123 Sunshine Lane, Springfield, IL 62702
  • Examining Physician: Dr. Maria Garcia, MD
  • Physician's Address: 789 Health St, Springfield, IL 62701
  • Physician's Phone Number: (217) 555-1234
  • Physician's Illinois License No.: 036.123456
  • Date of Most Recent Examination: April 22, 2026
  • Tuberculosis Test Type: Mantoux
  • Date TB Test Administered: April 22, 2026
  • Date TB Test Read: April 24, 2026
  • TB Test Result: Negative
  • Physician's Assessment: The individual is free from communicable diseases and has no physical or mental condition that would interfere with the child care responsibilities.
  • Physician's Signature Date: April 24, 2026

What this filled form sample shows:

  • Clearly indicates the applicant's and child care facility's identifying information in Part I.
  • Provides a comprehensive medical assessment in Part II by a licensed physician.
  • Documents a mandatory Tuberculosis (TB) test with date, type, and a negative result.
  • Includes the physician's conclusive statement on the applicant's fitness to work with children, a critical component for compliance.
  • Contains the physician's signature, license number, and date, validating the medical report.

Form specifications and details:

Form Number: CFS 602
Form Name: Medical Report on an Adult in a Child Care Facility
Issuing Agency: State of Illinois Department of Children and Family Services (DCFS)
Use Case: Pre-employment medical clearance for a new staff member at a licensed Illinois child care center.
Purpose: To verify that an adult working or residing in a child care facility is free from communicable diseases and physically/mentally capable of performing their duties.
Categories: CAR forms, child care forms, Illinois state forms, Medi-Cal forms, medical forms, medical report forms, NJ state forms, PA state forms, state ID forms, Department of State forms, L.A. Care forms, VA medical forms
Created: January 31, 2026 01:27 AM
A sample of a completed State of Illinois CFS 602 Medical Report on an Adult in a Child Care Facility.