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Blank Kansas Ccl 029 Form

The Kansas CCL 029 form is a vital 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, ensuring that child care providers can meet the health needs of the children in their care. Completing this form accurately is crucial for the safety and well-being of every child enrolled in a child care program.

Outline

The Kansas CCL 029 form is an essential document designed to ensure that all children in licensed child care facilities receive appropriate medical care and attention. This form serves multiple purposes, primarily focusing on the medical history and immunization records of each child, including those of the provider's own children. Parents or guardians are responsible for completing the Medical Record and the History of Immunizations sections for every child under their care. This information is crucial, as it is transferable when a child moves to a different licensed child care facility, ensuring continuity of care. The form also collects vital details such as the child's personal information, emergency contacts, and health assessments. Additionally, it includes sections for documenting any allergies, medical conditions, and emergency medical care authorizations. By providing a comprehensive overview of a child's health, the CCL 029 form helps child care providers make informed decisions regarding the well-being of the children in their care.

Sample - 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

Click for PDF

Form Information

Fact Name	Description
Form Purpose	The CCL 029 form is designed to collect medical records and immunization histories for children in licensed child care facilities in Kansas.
Governing Law	This form is governed by Kansas Statutes Annotated (K.S.A.) 65-508(d) and K.S.A. 65-519(c), which outline immunization requirements for children in child care.
Completion Requirement	Parents or guardians must complete the Medical Record and History of Immunizations for each child, including the provider's own children.
Transferability	The completed Medical Record, History of Immunizations, and Child Health Assessment are transferable to another licensed child care facility if the child moves.
Emergency Contact	Parents must provide emergency contact information, including names, addresses, and phone numbers of authorized individuals.
Immunization Records	A Kansas Certificate of Immunizations (KCI) may be attached to the CCL 029 form as a substitute for the immunization history.
Child Health Assessment	The Child Health Assessment must be completed by a KDHE-approved nurse or a licensed physician, ensuring comprehensive health evaluation.
Exemptions	Parents can claim exemptions from immunization laws based on medical or religious grounds, but specific documentation is required.

Detailed Guide for Filling Out Kansas Ccl 029

Completing the Kansas CCL 029 form involves providing detailed information about your child’s medical history and immunizations. After filling out the form, it should be submitted to the appropriate child care facility as part of the enrollment process.

Obtain the Kansas CCL 029 form from the Kansas Department of Health and Environment website or your child care facility.
Fill in the child's information at the top of the form, including their first and last name, date of birth, and gender.
Provide your name and contact information as the parent or guardian, including your home address, phone numbers, and email address.
List the names and ages of other children in your family.
Identify persons authorized to pick up your child or to be notified in case of an emergency. Include their names, addresses, and phone numbers.
Enter your child’s physician and dentist contact information, along with your hospital preference for emergencies.
Indicate whether your physician has approved the use of any non-prescription medications for your child.
Answer questions regarding any existing medical conditions your child may have and provide additional information if necessary.
State if there have been any major changes at home that might affect your child.
Provide any additional instructions that may assist the child care provider in caring for your child.
Sign and date the form as the parent or guardian.
Complete the History of Immunizations section by recording the dates your child received each vaccine.
If applicable, complete the exemption section if your child is exempt from immunizations.
Complete the Child Health Assessment section, which must be filled out by a licensed physician or approved nurse.
Submit the completed form to your child care facility.

Obtain Answers on Kansas Ccl 029

What is the Kansas CCL 029 form?
The Kansas CCL 029 form is a medical record required for all children in licensed child care facilities. This includes the provider’s own children. It collects essential health information, including immunization history and emergency contact details.
Who needs to complete the CCL 029 form?
Parents or guardians must complete the CCL 029 form for each child enrolled in a licensed child care facility. This includes providing details about the child’s medical history and immunizations.
What information is required on the form?
The form requires the following information:
- Child's name, date of birth, and gender
- Parent or guardian contact details
- Names and ages of other children in the family
- Emergency contacts
- Child’s physician and dentist information
- Immunization history
- Any known allergies or medical conditions
Can I use another form for immunization records?
Yes, a Kansas Certificate of Immunizations (KCI) can be substituted for the immunization section of the CCL 029 form. You can attach it to the completed medical record.
What if my child has medical conditions or allergies?
If your child has any medical conditions or allergies, you must provide detailed information on the form. This information is crucial for the safety and well-being of your child while in care.
What if my child is exempt from immunizations?
If your child is exempt from immunizations, you must complete the exemption section of the form. You can either provide a physician's certification stating that immunization would endanger your child's health or declare a religious exemption.
Who can sign the Child Health Assessment section?
The Child Health Assessment section must be completed and signed by a nurse approved by the Kansas Department of Health and Environment (KDHE) or a licensed physician. If a Physician Assistant completes it, the supervising physician must also sign.
Where do I submit the completed CCL 029 form?
You should submit the completed form to the child care facility where your child is enrolled. They will keep it on file as part of the child’s health records.
How can I contact the Kansas Department of Health and Environment for more information?
You can contact the Kansas Department of Health and Environment at the following:
- Phone: (785) 296-1270
- Fax: (785) 296-0803
- Website: www.kdheks.gov/kidsnet

Common mistakes

When filling out the Kansas CCL 029 form, many individuals make common mistakes that can lead to delays or complications in the child care licensing process. Understanding these pitfalls can help ensure that the form is completed accurately and efficiently.

One frequent error is neglecting to provide complete contact information for the parent or guardian. This includes not only the names and addresses but also the phone numbers and email addresses. In case of an emergency, having accurate contact details is crucial. Missing this information can hinder communication and may even affect the child’s care.

Another common mistake is failing to include all required medical information. Parents often overlook the section asking about allergies or existing medical conditions. If a child has allergies or health issues, it is essential to provide this information to ensure the child’s safety while in care. Incomplete medical records can lead to misunderstandings about what care the child may need.

Many people also forget to sign the form. The signature of the parent or guardian is a critical component that validates the information provided. Without a signature, the form may be considered incomplete, leading to potential delays in processing.

In addition, some individuals do not check the appropriate boxes regarding immunization exemptions. The form clearly outlines two options for exemptions, but parents sometimes fail to indicate which one applies. This oversight can complicate the licensing process and may require additional follow-up.

Another mistake is not providing the child’s physician or dentist contact information. This information is necessary for the child care facility to contact health professionals in case of a medical issue. Omitting these details can create unnecessary obstacles in providing care.

Additionally, parents often forget to attach the Child Health Assessment form. This assessment is required for all children in licensed care, and failing to include it can result in the form being rejected. Ensuring that all necessary documents are attached is vital for a smooth application process.

Lastly, some individuals do not provide additional information about any major changes at home that might affect the child. Changes in a child’s environment can impact their behavior and well-being. Including this information can help caregivers provide the best possible support. Ignoring this section may leave caregivers unprepared to address the child’s needs.

Documents used along the form

The Kansas CCL 029 form is essential for documenting the medical history and immunizations of children in licensed child care facilities. However, it is often accompanied by several other forms and documents that help ensure comprehensive care and compliance with state regulations. Below is a list of these important documents.

CCL 010 - Authorization for Emergency Medical Care: This form allows parents to authorize emergency medical treatment for their child. It ensures that caregivers can act quickly in case of a medical emergency, detailing the necessary contact information and medical preferences.
Kansas Certificate of Immunizations (KCI): This document serves as an official record of a child's immunizations. It can be used in place of the History of Immunizations section in the CCL 029 form, simplifying the documentation process.
Child Health Assessment Form: Completed by a licensed physician or an approved nurse, this form provides a comprehensive health evaluation of the child. It includes information on medical history, physical examination results, and any special needs or treatments required.
Kan-Be-Healthy Assessment Form: This is a specific KDHE form that evaluates children's health and developmental milestones. It is acceptable for use alongside the CCL 029 form and is particularly useful for children in licensed day care settings.
Physician Health Assessment Form: Similar to the Child Health Assessment, this form is used to document a child's health status and is completed by a licensed physician. It is crucial for ensuring that children are fit for care in child care facilities.
School Health Assessment Form: This form is designed for school-age children and youth. It assesses their health and developmental needs, making it a valuable addition for children transitioning to school environments.
Emergency Contact Information Form: This document lists individuals who can be contacted in case of an emergency. It includes their names, addresses, and phone numbers, ensuring that caregivers have immediate access to necessary contacts.
Medication Administration Record: This form tracks any medications that a child may need during their time in child care. It ensures that caregivers administer medications safely and according to the prescribed instructions.
Allergy Action Plan: If a child has allergies, this plan outlines the necessary steps to take in case of an allergic reaction. It includes information on triggers, symptoms, and emergency procedures.

Each of these forms plays a vital role in ensuring that children receive safe and appropriate care in child care facilities. By maintaining accurate and up-to-date records, caregivers can better support the health and well-being of every child in their care.

Similar forms

Authorization for Emergency Medical Care (CCL. 010): This form is used to grant permission for medical treatment in emergencies. Like the Kansas CCL 029 form, it collects vital health information and parental consent for medical care. Both forms ensure that caregivers have the necessary information to act quickly in case of a medical situation.
Kansas Certificate of Immunizations (KCI): The KCI serves as an alternative to the immunization history section of the CCL 029 form. It documents a child's immunization status and is transferable between child care facilities. Both documents aim to provide proof of immunizations required for children in care.
Kan-Be-Healthy Assessment Form: This form is a type of health assessment required for children in licensed care. Similar to the Child Health Assessment in the CCL 029 form, it gathers comprehensive health information and must be completed by a qualified health professional. Both forms ensure that children's health is monitored and documented.
Physician Health Assessment Form: This document is also used to assess a child's health and is acceptable in place of the Child Health Assessment. It shares similarities with the CCL 029 form in that it requires a health professional's signature and details about the child's medical history, ensuring that caregivers have access to important health information.

Dos and Don'ts

When filling out the Kansas CCL 029 form, it is crucial to follow specific guidelines to ensure accuracy and compliance. Here are six essential do's and don'ts:

Do complete the Medical Record and History of Immunizations for each child in care.
Do provide accurate contact information for parents or guardians.
Do include the child's physician and dentist information.
Do sign and date the form to validate the information provided.
Don't leave any sections blank; incomplete forms may delay processing.
Don't forget to attach any additional pages if necessary for more information.

Adhering to these guidelines will help ensure a smooth submission process for the Kansas CCL 029 form.

Misconceptions

Misconceptions about the Kansas CCL 029 form can lead to confusion for parents and caregivers. Here are nine common misunderstandings:

The form is only for children in licensed facilities. In fact, it applies to all children in licensed child care facilities, including the provider's own children.
Parents do not need to provide immunization records. Immunization history is mandatory for all children, and a Kansas Certificate of Immunizations can be used in place of the form.
The medical record is not transferable. The medical record and history of immunizations can be transferred when a child moves to a different licensed facility.
Only licensed physicians can complete the Child Health Assessment. A nurse approved by KDHE can also perform and sign the assessment.
Exemptions from immunizations are easy to obtain. There are specific criteria that must be met for exemptions, including a certification from a licensed physician or a statement of religious beliefs.
All medications require a prescription. Non-prescription medications can be administered if the physician has approved their use, but this must be indicated on the form.
Health assessments are optional. A Child Health Assessment is required for all children in licensed child care, including those of the provider.
Emergency contact information is not necessary. It is crucial to provide emergency contact details, including names, addresses, and phone numbers of authorized persons.
The form can be filled out by anyone. Only parents or legal guardians should complete and sign the form to ensure accuracy and consent.

Understanding these misconceptions can help ensure that children receive the appropriate care and documentation required in Kansas child care facilities.

Key takeaways

Filling out the Kansas CCL 029 form is essential for ensuring that children in licensed child care facilities receive appropriate medical care and monitoring. Here are key takeaways to keep in mind:

Complete Medical Records: Parents must fill out the Medical Record and History of Immunizations for each child in care, including their own children.
Transferability: The Medical Record, History of Immunizations, and Child Health Assessment can be transferred if the child moves to another licensed facility.
Emergency Contact Information: Include names and contact details of individuals authorized to pick up the child or to be notified in emergencies.
Physician Approval: Indicate if the child's physician has approved any non-prescription medications that can be administered by the child care provider.
Immunization Records: A Kansas Certificate of Immunizations can be attached in place of the form to fulfill immunization requirements.
Exemptions: If a child is exempt from immunizations, parents must select the appropriate exemption option and provide required documentation.
Health Assessments: A Child Health Assessment must be completed and signed by a licensed physician or an approved nurse, ensuring the child is fit for care.
Regular Updates: Parents should keep the form updated with any changes in the child’s health status or family circumstances that may affect care.