Childcare Worker Health Evaluation Form
Please complete this form to assess your current health status and readiness to work in a childcare setting.
Full Name
*
First Name
Last Name
Date of Evaluation
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Have you experienced any of the following symptoms in the past 48 hours?
*
Rows
Yes
No
Fever or chills
1
2
Cough
3
4
Shortness of breath
5
6
Sore throat
7
8
Runny or stuffy nose
9
10
Nausea or vomiting
11
12
Diarrhea
13
14
Have you had close contact with anyone diagnosed with a contagious illness in the past 14 days?
*
Yes
No
Have you been diagnosed with any communicable diseases in the past month?
*
Yes
No
Are your routine vaccinations (including influenza and COVID-19) up to date?
*
Yes
No
Not Sure
How would you rate your overall health today?
*
1
2
3
4
5
Are you currently taking any medication that may affect your ability to safely care for children?
*
Yes
No
Do you have any physical or mental health conditions that may impact your work with children?
*
Yes
No
Submit Evaluation
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