How to Complete the California LIC 503 Health Screening Report

The California LIC 503 Health Screening Report is a one-page state form that certifies a person working in a licensed care facility is free from communicable disease and physically able to do the job. You complete the top half with your facility, position, and duty information, take the form to a licensed physician for a general health evaluation and a tuberculosis test, and return the signed original to the facility administrator to keep in your personnel file. Most people finish the whole process in a single medical visit.¹

Who Has to Complete One

The LIC 503 is for facility personnel, not residents. Every licensee, administrator, and employee who will have regular contact with clients in one of the covered facility types needs a completed form on file.² Those facilities are Residential Care Facilities for the Elderly (RCFEs), Community Care Facilities, Residential Care Facilities for the Chronically Ill (RCFCIs), and Child Care Facilities.¹

Volunteers are treated differently. At an RCFE, a volunteer only needs to sign a statement affirming good health; a full LIC 503 is not required.² At community care and child care facilities, volunteers still have to get a tuberculosis test but can verify general health with a signed statement rather than a physician’s screening.³

When the Screening Has to Happen

The deadline depends on where you work. For RCFE personnel, the screening must be performed no more than six months before employment or licensure, or within seven days after.² For Community Care Facilities, RCFCIs, and Child Care Facilities, the window is wider: up to one year before employment or within seven days after.³

Facilities generally prefer new hires to arrive with a completed form. The seven-day grace period exists, but an inspector who arrives on day eight and finds nothing on file will treat it as a deficiency.

Filling Out the Employee Section

Download the current form from the California Department of Social Services website.¹ The top portion is yours to complete before the doctor’s appointment. You will need to fill in:

Facility name and full physical address
Your name, age, and position title
The facility type (RCFE, community care, RCFCI, or child care)
Your expected work days per week and hours per day
A duty statement describing the tasks you will perform
The categories of people you will serve, such as infants, children, adults, elderly, developmentally disabled, physically handicapped, or mentally disordered⁴

Take the duty statement seriously. “Caregiver” gives the physician nothing to work with. Something like “assists residents with bathing, dressing, medication reminders, and transfers from bed to wheelchair” lets the doctor actually evaluate whether your health matches the physical demands of the role. If the duty statement is vague, the physician’s certification is vague, and the form can be flagged.

The form also contains an authorization for release of medical information. Sign and date that line. Without it, the physician cannot legally share the findings with the facility. There is no patient medical history section for you to complete; the form moves straight from your administrative details into the physician’s clinical evaluation.

What the Doctor Does

A licensed physician, or another provider working under a physician’s direction, completes the clinical half. The evaluation covers three things: your general physical condition, your ability to perform the duties you described, and any hazardous health condition, primarily communicable disease, that could put you, your coworkers, or the people in your care at risk.²

Tuberculosis Testing

Every LIC 503 includes a TB screening section. For RCFE personnel, the regulation specifically calls for a chest X-ray or an intradermal (Mantoux) skin test.² For community care and child care facilities, the regulation requires a “test for tuberculosis” without specifying the method, so a blood-based interferon-gamma release assay (IGRA) also qualifies.³ The physician records the test date, marks the result positive or negative, and notes any follow-up if it is positive. A blank TB section makes the whole form useless.

Signature and Credentials

The doctor signs the form, prints their name (or uses a physician’s stamp), and adds a phone number. That signature certifies the screening happened and the results are accurate. A form without the physician’s signature is incomplete. The licensing division may also call the provider to verify credentials, so the printed name and phone number matter as much as the signature itself.

Extra Step for Child Care Staff

If you work at a licensed child care center, the LIC 503 is only part of the picture. Since September 2016, California has required all child care center employees and volunteers to show proof of immunization against influenza, pertussis, and measles. The influenza vaccine must be received between August 1 and December 1 each year. You can decline the flu shot by submitting a written declaration, and a physician can grant a medical exemption from any of the three vaccines. New hires who still need to gather immunization records may work conditionally for up to 30 days after signing a statement that they have been vaccinated.⁵

Where the Finished Form Goes

The completed LIC 503 does not get mailed to the state. The physician hands it back, and it goes to the facility administrator, who files the signed original in your personnel record. The facility keeps it on-site and produces it on demand when the Community Care Licensing Division inspects. The form is specifically listed among the documents inspectors look for during licensing visits.⁶

Health screening records should be stored separately from general personnel files. Under the Americans with Disabilities Act, medical information collected through employment-related examinations has to be kept in a confidential medical file with restricted access, not mixed in with performance reviews and payroll paperwork.⁷ A locked medical folder per employee is the standard approach.

What Happens if the Form Is Missing or Wrong

A facility that cannot produce a valid LIC 503 during an inspection is cited. For child care centers, Title 22 sets a penalty of $50 per day for each cited serious deficiency that goes uncorrected past the deadline in the notice, up to $150 per day, with repeat violations of the same regulation within 12 months triggering an immediate $150 penalty.⁸ Penalty structures for RCFEs and other facility types sit in separate sections and may differ in amount, but the pattern is the same: the inspector identifies the deficiency, issues a notice, and penalties accrue for every day it stays uncorrected.

The most common reasons a completed LIC 503 gets flagged are worth knowing before you hand yours in:

The physician did not sign, or signed without a printed name or phone number.
The TB section is blank or missing the test date and result.
The screening date is more than six months before an RCFE start date, or more than a year before a start date at another facility type, making it expired.
The duty statement is too vague for the physician to certify fitness for the actual work.
Only a photocopy is on-site. Inspectors expect the signed original.

Who Pays

The form itself is free to download. The medical appointment and TB test are where costs come in, and California regulations do not explicitly assign those costs to the employer or the employee. Most facilities either send new hires to a designated clinic, reimburse the visit, or fold it into onboarding, so in practice you should ask the facility how they handle it before you book the appointment yourself.

1
California Department of Social Services. Health Screening Report – Facility Personnel LIC 503
2
New York Codes, Rules and Regulations. California Code of Regulations Title 22 Section 87411 – Personnel Requirements General
3
Legal Information Institute. California Code of Regulations Title 22 Section 101216 – Personnel Requirements
4
California Department of Social Services. LIC 503 – Health Screening Report – Facility Personnel
5
California Legislative Information. California Health and Safety Code Section 1596.7995
6
Legal Information Institute. California Code of Regulations Title 22 Section 87818 – Application for License
7
U.S. Equal Employment Opportunity Commission. Enforcement Guidance: Preemployment Disability-Related Questions and Medical Examinations
8
New York Codes, Rules and Regulations. California Code of Regulations Title 22 Section 101195 – Penalties