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

Check this box if the individual can meet the strength and mobility requirements to care for children aged 0–2 years.

Check this box if the individual can meet the strength and mobility requirements to care for children aged 2–6 years.

Check this box if the individual can meet the strength and mobility requirements to care for children aged 7–12 years.

Check this box if the individual can meet the strength and mobility requirements to care for children aged 12–18 years.

Check this box if the examiner has identified one or more medical conditions that would contraindicate the person from serving as a Food Handler or Child Care Facility Driver.

Check this box if the examiner has determined there are no medical conditions that would contraindicate the person from serving as a Food Handler or Child Care Facility Driver.

Enter a clear, concise description of any medical condition(s) or reason(s) that would contraindicate this person from serving as a food handler or child care facility driver; if none, leave blank or write 'None'. Fill only if 'Any contraindicating conditions — Yes' is 'Yes'.

Enter the date when the medical examination was performed.

Enter the facility's street address, including building number and street name and any apartment or suite information if applicable.

Enter the city where the facility is located.

Enter the facility's postal ZIP code (typically five digits).

Enter the name of the county in which the facility is located.

Enter the full legal name of the licensee or licensed facility where the person is employed or volunteers.

Enter the first line of the examiner's findings, observations, or comments for the fifth reexamination.

Enter the second line of the examiner's findings, observations, or comments for the fifth reexamination.

Enter the third line of the examiner's findings, observations, or comments for the fifth reexamination.

Enter the fourth line of the examiner's findings, observations, or comments for the fifth reexamination.

Enter the date when the fifth reexamination was performed.

Enter the examining physician's printed name and state license number for the fifth reexamination.

Enter a concise summary of any medical or emotional problems or conditions, if any, that may affect the individual's ability to work, volunteer, or reside in a child care facility.

Enter the first line of the reexamination narrative, such as primary findings, diagnosis, or key observations.

Enter the second line of the reexamination narrative as a continuation of findings, symptoms, or assessment details.

Enter the third line of the reexamination narrative to record further observations, test results, or treatment notes.

Enter the fourth line of the reexamination narrative for any remaining comments, recommendations, or follow-up instructions.

Enter the date when this reexamination was performed.

Enter the physician's full printed name followed by their state medical license number.

Enter the detailed findings, observations, or comments from the fourth reexamination as free‑form text.

Enter the date on which the fourth reexamination was performed.

Enter the examining physician's printed name followed by their state medical license number.

Check this box if you have discussed the importance of immunizations for adult child care providers with this individual and have recommended the following immunizations.

Check this box if you have not discussed the importance of immunizations for adult child care providers with this individual.

Enter the immunizations the clinician recommends for this adult (list vaccine names and any specific doses or schedules to be given).

Enter the name and any details of the other test or exam performed (describe the test or procedure being reported).

Enter the date the other test or exam was performed.

Enter the result or findings of the other test (for example: positive, negative, normal, abnormal, or a short result description).

Enter the name or brief description of the other test or exam given (e.g., chest X‑ray, alternative tuberculin method, specific lab test).

Enter the date the other test or exam was performed.

Enter the result or findings of the other test or exam (e.g., positive, negative, description of abnormal findings, numerical value if applicable).

Enter the full legal name of the adult being examined (first, middle initial if used, and last name).

Provide the birth date of the person being examined.

Enter the physician's street address, including number and street name and any apartment or suite information.

Enter the city where the physician's office or practice is located.

Enter the state or territory for the physician's office (use the preferred local form, e.g., postal abbreviation or full name).

Enter the ZIP or postal code for the physician's office location.

Enter a phone number where the physician or the physician's office can be reached.

Enter the physician’s full printed name followed by their state medical license number in the same field so the provider and their license can be identified.

Check this box if the person examined is a caregiver at a day care or group day care home.

Check this box if the person examined works as a food handler in the child care facility (see Section B for additional requirements).

Check this box if the person examined is a member of the child care staff providing care to children.

Check this box if the person examined serves as a driver for the child care facility (see Section B for additional requirements).

Check this box if the person examined is employed in another staff role at the child care facility that is not covered by the caregiver or child care staff categories.

Check this box if the person examined volunteers at the child care facility.

Check this box if the person examined is a member of the household of someone associated with the child care facility.

Check this box when the examiner determines the individual is free from symptoms of communicable disease and is medically and emotionally fit to work, volunteer, or reside in a facility caring for children.

Check this box when the examiner determines the individual is not medically and/or emotionally fit or is not free from communicable disease to work, volunteer, or reside in a facility caring for children.

If you checked “No” for fit to work/volunteer/reside, provide a brief explanation describing why the individual is not medically or emotionally fit to work, volunteer, or reside in the child care facility. Fill only if 'Recommendation - Fit to Work/Volunteer/Reside: No' is 'No'.

Check this box if the individual has received one dose of the Tdap (tetanus, diphtheria, pertussis) vaccine.

Check this box if the individual has received two doses of the MMR (measles, mumps, rubella) vaccine or is known to be immune to MMR.

Check this box if the individual has a medical contraindication and is not medically indicated to receive one dose of the Tdap vaccine.

Check this box if the individual has a medical contraindication and is not medically indicated to receive two doses of the MMR vaccine.

Enter the examining physician's printed full name followed by their state medical license number for the first physician entry of the second reexamination.

Enter the examining physician's printed full name followed by their state medical license number for the second physician entry of the second reexamination.

Enter the examining physician's printed full name followed by their state medical license number for the third physician entry of the second reexamination.

Enter the examining physician's printed full name followed by their state medical license number for the fourth physician entry of the second reexamination.

Enter the date of the second reexamination for this entry.

Enter the examining physician's printed full name followed by their state medical license number for this physician entry of the second reexamination.

Enter the first line of the physician's findings, observations, or notes for the sixth reexamination.

Enter the second line of the physician's findings, observations, or notes for the sixth reexamination.

Enter the third line of the physician's findings, observations, or notes for the sixth reexamination.

Enter the fourth line of the physician's findings, observations, or notes for the sixth reexamination.

Enter the date on which the sixth reexamination was performed.

Enter the physician's printed name and the physician's state license number for the sixth reexamination.

Enter the detailed findings, observations, or comments recorded for the third reexamination.

Enter the date when the third reexamination was performed.

Enter the physician's printed name and the state license number for the doctor who performed the third reexamination.

Enter the date the tuberculin test (Mantoux) or chest X‑ray was performed for this individual.

Enter the test result from the tuberculin test or chest X‑ray (for example: negative, positive, or induration size in millimeters).