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.
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. |
Created: January 31, 2026 01:27 AM
