CERTIFICATE OF MEDICAL EXAMINATION OF APPLICANTS FOR FIRST EMPLOYMENT IN A CALIFORNIA SCHOOL DISTRICT OR COUNTY SUPERINTENDENT OF SCHOOLS OFFICE
______________________________(Name) School District; County Office
Name: | Last | First | Middle |
Address: | Street | City | Zip Code |
To the Physician:
The medical examination required of a person employed in a certificated position for the first time in a California School District or County Superintendent of Schools Office to determine freedom from any disabling disease unfitting the person to instruct or associate with children should be evaluated on the basis of the function which will be required of the applicant upon employment. A brief description of functions is attached to this form.
Disabling disease should be considered in terms of:
Details | |||
Check Every Item YES NO | (Relate to functions to be performed) | ||
1. | Is there evidence of disabling disease of the musculo-skeletal, cardio-vascular, nervous, gastro-intestinal, genito-urinary, endocrine systems? ______ | ||
2. | Is there evidence of disabling disease affecting vision, hearing or speech? ______ | ||
3. | Is there evidence of disabling metabolic disease? ______ | ||
4. | Is there evidence of infectious disease in a communicable stage? ______ | ||
5. | Is there evidence of drug dependency including alcoholism? ______ | ||
6. | Is there evidence of any other disabling disease? ______ |
On the basis of my medical examination on (date) ____________ the above named individual is free from disabling disease, except as noted above, which I believe unfits the individual to instruct, in the position for which application is being made, or to associate with children.
___________________________ | /___________________________ | ||||
Signature of Physician | Date | ||||
___________________________ | /___________________________ | ||||
Name of Physician (print) | License # |
To be returned by the examining physician directly to the school district or County Office requesting the examination.
Cal. Code Regs. Tit. 5, § 5504
2. Amendment of section and repealer of NOTE filed 9-23-77; effective thirtieth day thereafter (Register 77, No. 39).
3. Renumbering of Section 5505 to Section 5504 filed 11-9-79; effective thirtieth day thereafter (Register 79, No. 45). For history of former Section 5504, see Register 78, No. 45.
4. Change without regulatory effect amending subsections (a) and (c) filed 12-23-2010 pursuant to section 100, title 1, California Code of Regulations (Register 2010, No. 52).
Note: Authority cited: Section 44843, Education Code. Reference: Section 44843, Education Code.
2. Amendment of section and repealer of NOTE filed 9-23-77; effective thirtieth day thereafter (Register 77, No. 39).
3. Renumbering of Section 5505 to Section 5504 filed 11-9-79; effective thirtieth day thereafter (Register 79, No. 45). For history of former Section 5504, see Register 78, No. 45.
4. Change without regulatory effect amending subsections (a) and (c) filed 12-23-2010 pursuant to section 100, title 1, California Code of Regulations (Register 2010, No. 52).