Foster/Adoptive Parent Health Report

This form is used during the initial licensing/approval process for prospective foster and adoptive parents. It documents completion of a physical examination, completion of TB tests for the applicant and his or her family and household members and immunizations for children living in the home. This form is also used at the time of license renewal for foster families to document updates of TB tests and immunizations for children living in the home.

• Part A is to be completed by the applicant's physician or physician's assistance.
• Part B is to be completed by a nurse, physician's assistance or physician.
• Part C may be completed by the applicant.

If you have a question about this form, please call (605) 773-3227.