Model Form STAFF HEALTH REPORT Physicians Statement a copy of this form to each employee to be given to hisher examining ID: 413922
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Religiously Exempt Child Day Centers Model Form STAFF HEALTH REPORT Physician's Statement _______________________________________________________________________ a copy of this form to each employee to be given to his/her examining physician. The top portion of the form should be completed by the employee; the bottom portion must be completed and signed by the physician, physician's acceptable. Staff must have this form completed and submit it on an ANNUAL basis. ________________________________________________________________________ Name of Religious Institution Name of Staff Member ________________________________________________________________________ This statement is signed in compliance with the Code of Virginia, Section 63.2-1716. I certify that __________________________________________is free from any disability which would prevent him/her from caring for children under his/her tioner's Signature: ______________________________________ Physician/Nurse Practitioner's Printed Name: ___________________________________ Date __________________________________________ (Month/Day/Year) Address: ________________________________________________________________ Number_________________________________________________________________ 032-05-0977-01-eng (06/08)