Employee’s Name_________________________Birth Date ______________

General Health__________________________________________________

Date and Results of Tuberculin Test__________________________________

Childhood Diseases: _____________________________________________
 
 
 
 
 
 
 
 
 

Significant Illnesses or Physical Conditions: _____________________________
 
 
 
 
 
 

The above named person is free of any contagious or infectious disease and is in good physical condition and able to work at a nursery school facility.
 

_______________ ____________________________
Date                                         Physician