Staff, Volunteer, and Household Member Medical Statement 2026

1. Click ‘Get Form’ to open the Staff, Volunteer, and Household Member Medical Statement in our editor.
2. Begin by filling in the Program’s Name and Facility ID Number at the top of the form. Ensure that all information is printed clearly.
3. Next, provide the Person’s Name and Date of Birth. This section is crucial for identifying the individual associated with this medical statement.
4. Select the appropriate TYPE OF PROGRAM and ROLE from the provided options. This helps categorize the individual's involvement accurately.
5. The Medical Status section must be completed by a qualified health care provider. They will assess and indicate any communicable diseases or physical conditions affecting child care duties.
6. If applicable, ensure that the Tuberculin Test Information is filled out on the reverse side by a health care professional. This includes test results and any necessary clarifications.
7. Finally, both sides of the form require signatures where indicated. Make sure to review all entries for accuracy before submission.

Start using our platform today to easily complete your medical statement online for free!