Ill. Admin. Code tit. 77, pt. 350, subpt. Q, app D, form B

Current through Register Vol. 49, No. 2, January 10, 2025

Form B - Forms For Day Care in Long-Term Care Facilities

								SAMPLE
PHYSICIAN PERMISSION FORM
___________________________________has applied for admittance to the day care program at _____________________________. Please supply the following information and also give written permission for _____________________ to participate in the activity program.
			Physical Limitations				________________________________
				_________________________________________
			Degree of activity				________________________________
				_________________________________________
			Can day care resident be involved in activities outside of the facility (in
the community)?		_________________________________________
			Has ________________________been evaluated within the last 30 days
and found to be free of communicable and infectious disease?
				_________________________________________
				_________________________________________
			Medications and/or treatments and diet needed by day care resident
during the period of time spent in the facility.
				_________________________________________
				_________________________________________
			Can day care resident take own medication?							_______________________
			Allergies			_________________________________________
Date	_______________				Signature of Physician				_______________

Ill. Admin. Code tit. 77, pt. 350, subpt. Q, app D, form B

Added at 9 Ill. Reg. 10876, effective July 1, 1985