Form LIC503 Health Screening Report - Facility Personnel - California

Form LIC 503 Instructions

Follow these steps to complete LIC 503 Form:

1. Identify the facility in question by its name and address.
2. Name the person whose health condition is described in the report, add their age, job title, the type of facility, the number of days they work per week, and the number of hours they work per day.
3. List tasks and responsibilities of the applicant to be hired or of the employed individual.
4. Check the box to indicate the types of persons the applicant or employee will serve. If you do not see an appropriate category, use free space to write your own option.
5. Obtain permission of the employee or job candidate to release their medical information. They must sign and date the form and state their address.
6. Provide a brief description of the applicant's or employee's health. They will not be allowed to work in the facility if they have a communicable disease.
7. Examine the individual's ability to work. They must be capable of performing tasks and dealing with responsibilities listed in the form.
8. If the candidate or employee has any health issues that may endanger other people, these conditions and illnesses must be indicated in the report.
9. State the dates of the screening and the tuberculosis test. If the test was positive, describe the action you took.
10. Write down your name or use a stamp to verify the details in the report. Add your telephone number, sign and date the document.