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MEDICAL CLEARANCE REQUEST

Michigan Deparlment of Hunran Services
Cffice of Children and Acult Licensing
APPL ICANTiLICEN SEE INFORMATION
L-rcanse Nurnbei

:ac;i! tyiForxle Llail- e

Staie

ciry

FacililiHor:re Address {Sireel N.rnbe: and Name)

:icensirg Corsulisni iNama Adcress, Pro:u)

i- cense Appl

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PLEASE

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Zip Ccde

calioi =}pe

Aciult Foster Care i24-Hcur Care)

Child Fsster Care i24-Hcur Care)

Child Caie {i-ess Than 24-f'icur Care}
Capacit-v

PATIENT INFORI$ATION {To be Cnrnpleted by Patient} {Please Print or Type)

N.rne (l-ast. First. Micoie Jr., ll, etc.)
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r,rt-

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Xarne)

Add ress

RELEASE OF INFORMATION (To he Gornpleted by Patient)

Dale

I authorize the release of meCical informaiior concerning -ne

lo tne care facilily listec above and tc the Michigan -FEFI s^sCna:rrre
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Depafiment of Human Services, Offlce cf Chitcren ano Adult
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Lrcensing, {or ihe puroose oi CetermininE m,v suitability tc
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provide or be assoclated ,,!jlh ihe care cf chlidren/dependent Physrcran's Nama (Please PRINT or TYPtr)

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aiults.
MEDICAL INFORITAflON (To be Cornpleted by Fhysician)
This individual is, or will be, employed in a childldependent adult care setlingIt as necessary to estabiish that ilrose providing care are. in such pnysical and rnental condition and health as nrrt lo adver:sely
iflect thc heaith or safety of a child/dependeniadult and the quality and rnanner of his/her careTo assist us in lhis determination, you are being asked to answer the totlowlng"
for T.3 ?

rf ves

sectic r ior explana|cns)

ccndilo{l trrc igaltl'? lJse
Na chysicallrnenial condi:ron or health pioblem exisls tha: vrcuid lirnit tre abirrf,v ic woi'k with or arcunc ch idrerUCepenceni adul:sph;,5;"aU-"n,al cOnditicn or heallh o.obiem exisG that woulo not irmit $e abrlitv to work wilh )r around clrldren,lcependent adults.
Exoiair in Coinrnents if ieasonable acccmrnodation may be neededphysrcaV|:1enral ccniition cr heal'lh orc3rrr] exists nfiich wo;id affeci the aciliry,to rrnrk v/ith or al'cunC childienldepenCer:t adutts. vrith
olsithoul reasorable acccmmod 3tion.
,-ou desccbe ihe palle',t's general

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recommencaiior? f Yes
Te,eohene \ r.xDei
Da:e
-

by the iicensing consr;liant regarding ycur

S,gnat-{e

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AUTHOR.[Y 1973 eA i

1gl9 rA

OCA--37,'4

218

Applicalron for iicensure rnay be Cenec

-0il P:evicus editjors 3rf5 & f 0-05 iray

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Separtment cf l-lurran Serrbes (DhS) '#il! not cirsctirrnate. againsl 3ry

rndridual c" group becatlse of izce, sex, religion, 3ge, na+ional criqir, corr.
lerqh:. ,rre qf t, marr',=t s-ralrus, pollllcai Delleis or ClsaDlilry. l, you neeo neip

RESPCNSE: Vo;uniary

PENALTY.

Ef

be

usei 1'/S'/!ord

rvUii-eadn{,wrrting }'ea.rng,d:c..under'theArne-canswrthfisaballtiesAct
ineeds kros.n to a DHS