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Kansas Ccl 029 Template

The Kansas CCL 029 form is a crucial document required by the Kansas Department of Health and Environment for all children in licensed child care facilities. This form collects essential medical information, including immunization history and health assessments, to ensure the well-being of children in care. Parents and guardians play a vital role in completing this form accurately to facilitate smooth transitions between care facilities.

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The Kansas CCL 029 form is a crucial document for parents and guardians enrolling their children in licensed child care facilities. This form serves as a comprehensive medical record that captures essential health information for each child, including the child's name, date of birth, and contact details for parents or guardians. It requires parents to provide a detailed history of immunizations, ensuring that children are up-to-date with their vaccinations, which is vital for their health and safety in a group setting. Additionally, the form includes sections for emergency contact information, medical conditions, and any allergies that may affect the child's care. It also allows for the inclusion of a Child Health Assessment, which must be completed by a qualified healthcare provider, ensuring that all children in care receive appropriate health evaluations. By collecting this information, the Kansas CCL 029 form not only facilitates a safe environment for children but also helps child care providers understand the unique needs of each child in their care.

Kansas Ccl 029 - Usage Instruction

Completing the Kansas CCL 029 form is an essential step for parents or guardians enrolling their child in a licensed child care facility. The information collected is crucial for ensuring the health and safety of your child while in care. Here’s how to fill out the form correctly.

Gather necessary information: Before starting, collect your child's personal details, medical history, and immunization records.
Fill out the child's information: Enter the child's first and last name, date of birth, and gender in the designated sections.
Provide parent/guardian information: Include your name, home address, phone numbers, and email address. Make sure to specify the best way to contact you.
List other children: Indicate the names and ages of any other children in the family.
Emergency contacts: Write down the names, addresses, and phone numbers of individuals authorized to pick up your child or to be contacted in an emergency.
Child’s healthcare providers: Provide the names and phone numbers of your child's physician and dentist, as well as your hospital preference for emergencies.
Medication approval: Indicate whether your physician has approved the use of any non-prescription medications for your child.
Health conditions: Answer questions regarding any health conditions your child may have and provide additional information if necessary.
Changes at home: Note any significant changes at home that might affect your child in care.
Special instructions: Include any other information that may help the caregiver understand your child’s needs.
Sign and date: As the parent or guardian, sign and date the form to confirm that all information provided is accurate.

Once you have completed the Kansas CCL 029 form, ensure that you keep a copy for your records. Submit the form to the child care facility as soon as possible, as they may require it for enrollment. Timely submission will help ensure a smooth transition for your child into their new environment.

Dos and Don'ts

When filling out the Kansas CCL 029 form, here are some essential dos and don’ts to keep in mind:

Do provide accurate and complete information for each child, including their name, date of birth, and immunization history.
Do ensure that the parent or guardian signs the form before submission.
Do attach any additional pages if you need more space for emergency contacts or health information.
Do double-check that all required sections are filled out, especially regarding allergies and medical conditions.

Don't leave any sections blank; incomplete forms may delay processing.
Don't forget to provide your child's physician's contact information.
Don't submit the form without reviewing it for accuracy.
Don't include any unnecessary personal information that is not relevant to the child's health care.

Form Properties

Fact Name	Details
Governing Law	The CCL 029 form is governed by Kansas Statutes Annotated (K.S.A.) 65-508(d) and K.S.A. 65-519(c).
Purpose	This form is used to maintain a medical record for all children in licensed child care facilities, including the provider’s own children.
Completion Requirement	Parents or guardians must complete the Medical Record and History of Immunizations for each child.
Transferability	The Medical Record and History of Immunizations are transferable when a child moves to another licensed facility.
Emergency Medical Care	Parents must provide information regarding authorization for emergency medical care on the CCL 010 form.
Immunization Records	A Kansas Certificate of Immunizations (KCI) can be attached as a substitute for the form.
Health Assessment Requirement	A Child Health Assessment must be completed and signed by a licensed physician or an approved nurse.
Exemption Options	Parents can exempt their child from immunizations under specific conditions, including medical or religious exemptions.

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Preview - Kansas Ccl 029 Form

CCL. 029	Kansas Department of Health and Environment
Rev. 8/2011	Bureau of Child Care and Health Facilities
	Child Care Licensing Program
	1000 SW Jackson, Suite 200
	Topeka, KS 66612-1274
	Phone (785) 296-1270 Fax (785) 296-0803
	Website: www.kdheks.gov/kidsnet

MEDI CAL RECORD FOR ALL CHI LDREN I N CHI LD CARE FACI LI TI ES,

I NCLUDI NG PROVI DER’S OWN CHI LDREN

Parents are to complete the Medical Record and the History of I mmunizations for each child in licensed child care facilities. The Medical Record, History of I mmunizations, and Child Health Assessment are transferable w hen the child moves to another licensed child care facility.

Child’s First Day in Child Care

Name of Child Care Facilit y

Child’s Name

Date of Birth

Gender

First

Last

MM/ DD/ YYYY

M/ F

Parent/ Guardian I nformation

Name

Home Address

Street

City

Zip Code

Street

City

Zip Code

Home Phone Number

Work Address

Street

City

Zip Code

Street

City

Zip Code

Work Phone Number

Cell Phone Number

E-mail Address

Best way to contact

Names and ages of children in family

Persons aut horized to pick up the child or to notify in case of emergency. I nclude name, address, and telephone number. Attach an additional page, if necessary.

Child’s Physician			Phone Number
Child’s Dentist			Phone Number

Hospital Preference (for emergencies)

Has your physician approved the use of any non-prescription medications for your child such as acetaminophen, cough

syrup, or ointments that can be given by the child care provider? No Yes, as follows:

Does your child have any of the following conditions (yes or no) ? I f yes, provide information on Aut horization for Emergency Medical Care form CCL. 010.


	Allergies	Frequent sore throats/ colds			Ear Aches
	Asthma	Speech, Visual, Hearing			Diabetes
	Epilepsy/ Seizures	Other
I f yes answered to any above, please provide additional information
Have there been major changes at home that might affect your child in care?			No	Yes, as follows:

Please provide additional information or special instructions that will help t he person caring for your child.

Parent/ Guardian Signature:____ ____________ ___________________ ______ Date:_________ ____

History of I mmunizations

Required for all children in child care facilities, including the provider’s ow n children. A Kansas Certificate of I mmunizations ( KCI ) may be substituted for this form and attached to the completed Medical Record.

Child’s Name:			Date of Birth:
	First	Last		MM/ DD/ YYYY

Section I . For a recommended schedule of immunizations, refer to the current schedule published by the Advisory Committee on I mmunization Practices ( ACI P) .

Vaccine		Record the Month. Day and Year that each Dose of Vaccine w as Received
	1 st		2 nd	3 rd	4 th	5 th		6 th
DTaP/ DT/ Td/ Tdap (Diphtheria,
Tetanus, Pertussis)
Polio

MMR (Measles, Mumps, and Rubella
combined)
HBV (Hepatitis B Vaccine)

				Hx of Disease:			Date of I llness:
Varicella (Chicken Pox)				Physician Signature

HI B (Hemophilus I nfluenzae Type B)

PCV7 (Pneumococcal Conjugate)

HEP A (Hepatitis A)

Rotavirus * * Recommended < 8 mo of
age; not required
I nfluenza( Flu) * * Recommended
annually > 6 mo of age; not required

Section I I .

Complete this section only if your child is exempted from the law requiring immunizations [ K.S.A. 65 - 508( d) ] .

Section I I . Complete Section below only if your child is exempted from law s requiring requiring

The following two options are the ONLY exemptions allowed by law. Please check either ( A) or ( B) below and immunizations [ K.S.A. 65 - 508( d) and K.S.A. 65 - 519( c) ]

complete as required:

( A) Certification from licensed physician stating that immunization w ould endanger child’s life:

Exempt from following immunizations:

DTP

Pertussis Only ____Tetanus ____Polio

MMR

Rubella Only

Hep A

Hep B

Hib

_PCV7 ____Ot her

Physician’s Signature (required): ________________________________________________Date:_______________

( B) My child is exempt under the law from immunizations. As the Parent or Legal Guardian, I state that I am an adherent of a religious denomination w hose teachings are opposed to immunizations.

Section I I I .

Parent/ Guardian Signature:____ ____________ ___________________ ______ Date:_________ _______

CCL. 029a

Rev. 08/2011

Child Health Assessment

The Child Health Assessment form is to be completed and signed by a nurse approved by KDHE to perform Child Health Assessments or a Licensed Physician. I f a Physician Assistant (PA) completes the Child Health Assessment, t he signature of the Licensed Physician authorizing the PA is to be included at the bottom of this form.

A Child Health Assessment, recorded on a KDHE Form or other acceptable Forms mentioned below, is required for all children including children of the provider or staff in Licensed Day Care Homes, Group Day Care Homes, Child Care Centers and Preschools. A Kan-Be-Healthy Assessment Form is a KDHE Form and is acceptable, a Physician Health Assessment Form is acceptable, and a School Health Assessment Form is acceptable for school-age children or youth. The Health Assessment Form used should be attached to the KDHE Medical Record Form (CCL. 029) .

Child’s Name_______ __ ___________________ _____________ Date of Birth_________ __________

First

Last

Health history and medical information pertinent to routine child care and emergencies (describe, if any):

None

Do you see this child for regular health supervision:

 Yes  No

Allergies to food or medicine ( describe, if any):

None

List current medications (if any):

None

Length/ Height: ______ I N/ CM	% I LE_______		Weight: _____ LB/ KB % I LE_______
Physical Examination		 I f Normal	I f Abnormal - Comments

Head/ Ears/ Eyes/ Nose/ Throat

Teeth

Cardio/ Respiratory

Abdomen/ GI

Genitalia/ Breasts

Extremities/ Joints/ Back/ Chest

Skin/ Lymph Nodes

Neurologic & Developmental

Screening Tests		Screening Date	Note Here if Results are Pending or Abnormal

Lead

Anemia (HGB/ HCT)

Urinalysis (UA)

Hearing

Vision

Health Problems or Special Needs, Recommended Treatment/ Medications/ Special Care (Attach additional sheets if necessary)

None

Signature of Licensed Physician or Nurse approved for Child Health Assessments		Date

Print the Name of the I ndividual Signing Above		Phone Number

Address	City	Zip Code

➤ Kansas Ccl 029 PDF Form

Misconceptions

Misconceptions about the Kansas CCL 029 form can lead to confusion among parents and child care providers. Here are five common misconceptions, along with clarifications for each:

The form is only for children in licensed facilities. While the CCL 029 form is primarily designed for children in licensed child care facilities, it also applies to the provider's own children. This ensures that all children under care have their medical records documented.
Immunization records are optional. In fact, the history of immunizations is a required component for all children in child care facilities. Parents must complete this section to comply with state regulations.
Parents can submit the form at any time. There is a specific timeline for submission. Parents must complete the form before their child’s first day in child care. This helps ensure that caregivers are informed about any medical conditions or needs.
Only licensed physicians can complete the Child Health Assessment. This is not entirely accurate. A nurse approved by the Kansas Department of Health and Environment (KDHE) can also complete the assessment. If a Physician Assistant (PA) conducts the assessment, a licensed physician's signature is required.
All children must be immunized to attend child care. There are exemptions available under Kansas law. Parents can choose to exempt their child from immunizations for medical or religious reasons, but they must complete the appropriate sections of the form to document this.

Documents used along the form

The Kansas CCL 029 form is essential for documenting the medical records of children in licensed child care facilities. Several other forms and documents accompany this form to ensure comprehensive health information is collected. Below is a list of these documents, along with a brief description of each.

Authorization for Emergency Medical Care (CCL. 010): This form allows parents to give permission for emergency medical treatment for their child if they are unable to be reached during an emergency.
History of Immunizations: This document records the immunization status of the child. It may be substituted with a Kansas Certificate of Immunizations (KCI) if available.
Child Health Assessment: This form must be completed by a licensed physician or an approved nurse. It assesses the overall health of the child and includes information about any health concerns or special needs.
Kan-Be-Healthy Assessment Form: This is a specific KDHE form used to evaluate the health of children. It can be used in place of the Child Health Assessment.
Physician Health Assessment Form: Similar to the Child Health Assessment, this form is filled out by a physician to provide a detailed health evaluation of the child.
Medical Power of Attorney: To ensure your health care wishes are honored, consider utilizing a comprehensive Medical Power of Attorney form that designates a trusted individual to make decisions on your behalf.
School Health Assessment Form: This form is used for school-age children and documents their health status, including any medical concerns that may affect their school experience.
Medication Administration Record: This document tracks any medications given to the child while in care, ensuring proper dosage and timing are followed.
Emergency Contact Form: This form lists individuals who can be contacted in case of an emergency, providing essential information to caregivers.

These documents work together to create a complete picture of a child's health and well-being in a child care setting. Proper completion and maintenance of these records are vital for the safety and health of all children in care.