Child and Residential Care Facilities Division
825 North Capitol Street, NE, 2nd Floor
Washington, DC 20002
Phone: (202) 442-5929
Fax: (202) 442-9430 or (202) 442-4831

Information
Name:
Date of Birth:
Sex:	Male  Female
Phone Number:
Address:

I have examined the above-named and certify that he/she is:
1.  Free from disease in communicable form.
2.  As of this date, in satisfactory physical and mental health condition, capable of doing physical household tasks, supervise and give care to other people.
In addition to a general physical health examination, the following tests have been done:
Tuberculin test (Check One):	Tine  PPD
Date:	Result:
Chest X-Ray Date:	Result:
Remarks:

Date of Examination:

Telephone No:

___________________________
Address of Examining Physician

_______________________M.D.
Signature of Examining Physician