4434 1-2026

The document LDSS-4434-1 is a Caregiver Medical Statement form used to assess the health and fitness of individuals providing child day care. It requires completion by a qualified health care provider, confirming that the caregiver is symptom-free from communicable diseases and emotional disorders. The form includes sections for personal information, medical examination results, and tuberculin test information, emphasizing the importance of maintaining health standards in child care settings.

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Click ‘Get Form’ to open the 4434 1 document in the editor.
Begin by entering the Applicant Name and Date of Birth in the designated fields at the top of the form.
In the Medical Condition section, ensure a qualified health care provider completes and signs this part. They will need to indicate if the applicant is physically fit and symptom-free for child care duties.
For each question regarding communicable diseases and emotional disorders, select 'YES' or 'NO' as applicable. If any 'NO' responses are given, provide restrictions in the space provided.
On the reverse side, health professionals should complete the Tuberculin Test Information. Enter test results and sign where indicated.
Finally, review all entries for accuracy before submitting your completed form through our platform.

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