Submit the completed Illinois Certificate of Child Health Examination form to the respective child care facility as per their requirements. This may include submitting via email, fax, or in-person at the facility's office. Ensure that all sections are accurately filled and signed by the necessary parties before submission. For in-person submissions, hand-deliver the form to the child care facility administratively. For electronic submissions, scan and email the form to the facility's designated email address or upload it through their online portal if available. Always retain a copy for your records.

The Illinois Certificate of Child Health Examination should be updated annually or as required by the child care facility. Ensure the form is current for the school year 2024-2025 for uninterrupted enrollment.

The Illinois Certificate of Child Health Examination is designed to safeguard the health and well-being of children enrolling in licensed child care facilities. This form ensures that children have received necessary immunizations and that any health concerns or medical conditions are documented. By completing this form, parents and healthcare providers contribute to a safe and healthy environment in child care and educational settings. Healthcare providers play a crucial role in verifying and documenting the immunization records and health status of children. This form serves as an essential record for both the child care facility and parents, ensuring that the child's health needs are met. It also helps in identifying any special health requirements or conditions that need to be addressed. Timely submission of the Illinois Certificate of Child Health Examination is important for compliance and enrollment in child care programs. Parents should ensure that the form is completed accurately and submitted as per the facility’s guidelines. Keeping the form up-to-date is necessary for the continued health monitoring of children in care.

• 1. Student’s Name: Includes the child's last, first, and middle name.
• 2. Birth Date: The child’s date of birth (Month/Day/Year).
• 3. Sex: Indicates the child’s sex.
• 4. Race/Ethnicity: Indicates the child’s race or ethnicity.
• 5. School/Grade Level/ID#: Indicates the school, grade level, and ID number if applicable.
• 6. Address: The child’s street address, city, and zip code.
• 7. Parent/Guardian: Name and contact details of the child’s parent or guardian.
• 8. Immunizations: Section for the health care provider to fill in the immunization history with dates for each dose administered.
• 9. Health History: Section for the parent or guardian to complete the child’s health history including allergies, medical conditions, and medications.
• 10. Physical Examination: Section for the health care provider to document physical examination details such as height, weight, BMI, and any specific health screenings.
• 11. Vision and Hearing Screening: Results of vision and hearing screening conducted by a certified technician.
• 12. Alternative Proof of Immunity: For documenting clinical diagnoses or laboratory confirmation of immunity to specific diseases.

Failure to submit the Illinois Certificate of Child Health Examination can lead to the child's exclusion from child care facilities.

• Non-Compliance: Non-compliance with state requirements for child health examinations.
• Exclusion from Care: Child may be excluded from enrolling or attending child care facilities.
• Health Risk: Increased health risk due to lack of documented immunizations and medical history.

• 1. Child Care Enrollment: Used during the enrollment process in child care facilities.
• 2. School Admission: Required for admission into schools and preschools.
• 3. Health Record Keeping: Serves as a health record for parents and health care providers.
• 4. Immunization Tracking: Used to track and verify the child’s immunization history.
• 5. Emergency Preparedness: Provides critical health information for emergency scenarios.