How to Fill Out and Submit the NYC Staff Health Form

The NYC Staff Health Form is a one-page medical clearance that every adult working in a New York City childcare program must complete before starting work and again every two years after. You fill out the top with your personal and medical history; a licensed healthcare provider completes the rest after examining you, documenting a physical exam, a tuberculosis screening, and proof of required immunizations. The form is a free PDF from the NYC Department of Health and Mental Hygiene (DOHMH), and no one can begin working in a childcare setting without a signed, stamped copy on file at the facility.¹

Who Has to File One

Under 24 RCNY § 47.33, every person who regularly associates with children in a permitted childcare program needs a current Staff Health Form on file. The rule names teaching staff, substitute staff, volunteer workers, office workers, kitchen workers, maintenance workers, and students placed at the facility.² Job title doesn’t matter. An administrative assistant who shares space with children needs the same clearance as a lead teacher.

Before signing the certificate, the healthcare provider has to confirm that you are “physically and mentally able to perform assigned duties.” If a health condition would prevent you from safely supervising children, the provider cannot sign off.²

Where to Get the Form

The official document is titled “NYC Bureau of Child Care Staff Health Form” and is available as a free PDF from the DOHMH website.¹ Your employer may also hand you a printed copy during onboarding. Bring the blank form to your medical appointment either way, so the provider can fill in their sections during the visit rather than transferring notes afterward. That avoids the most common source of errors.

What You Fill In

The top portion of the first page is yours. You’ll need to provide:

Personal details: full legal name, date of birth, sex, home address, and telephone number.
Employment details: date of employment, job title, and the specific program or classroom where you’ll work.
Past medical history: a checklist where you mark “Yes” or “No” for conditions including hypertension, heart disease, diabetes, seizure disorder, chronic lung disease, mental illness, alcohol or substance use concerns, physical disabilities, allergies, and hepatitis. An open “Other” field lets you note anything not listed.

Make sure your name and job title match what your employer has on file. A mismatch between your form and payroll records can slow your start date. Fill in every field. A blank checkbox counts as incomplete during a DOHMH inspection.

What Your Healthcare Provider Fills In

The rest of the form belongs to your licensed physician, nurse practitioner, or physician assistant. This is the bulk of the document, and it covers the physical exam, TB screening, immunization records, and the provider’s final certification.

Physical Examination

Your provider records your height, weight, and blood pressure, then explains any positive findings, chronic medications, or ongoing treatments. The form includes a tobacco use section and an optional space for laboratory tests. At the bottom, the provider writes a diagnosis and follow-up plan if anything needs attention.

The certification statement reads: “On the basis of my findings as indicated above and my knowledge of the staff member, I find that the above person is fit to give adequate child care to children in a day care setting at this time.”¹ Your provider must sign and date this statement and include their printed name, license number, telephone number, address, and an agency stamp. Without the license number and stamp, the form is legally insufficient and your facility director will send you back to get it corrected.

Tuberculosis Screening

Every Staff Health Form requires a TB test result. The form accepts either a PPD Mantoux skin test or a QuantiFERON Gold blood test.¹ For the skin test, the provider injects a small amount of tuberculin under the skin and reads the result 48 to 72 hours later, recording the induration in millimeters. The blood test requires a single draw and typically returns results within a few days.

If either test comes back positive, your provider must order a chest X-ray to rule out active tuberculosis. The form has a dedicated section for the X-ray date, location, and findings. A positive skin test by itself does not disqualify you; many people carry latent TB that poses no risk to others. What matters is whether the X-ray and symptom screening confirm you are free of active disease. Your provider documents the results and any recommended treatment directly on the form.

Required Immunizations

The immunization section is where forms get rejected most often, because the requirements go beyond what many adults remember getting. Under § 47.33(c)(1), every staff member and volunteer must show proof of immunity to all of the following:²

Measles: two doses of measles-containing vaccine, at least 28 days apart.
Mumps: two doses of mumps-containing vaccine.
Rubella: one dose of rubella-containing vaccine.
Varicella (chickenpox): two doses of varicella-containing vaccine. A provider-documented history of chickenpox or shingles is an acceptable substitute.
Tdap: one dose of tetanus, diphtheria, and acellular pertussis vaccine.

For measles, mumps, rubella, and varicella, a blood test (titer) showing detectable antibodies also satisfies the requirement. A self-reported history of having had measles, mumps, or rubella does not count; only varicella accepts a documented disease history as proof.² If you were born on or before December 31, 1956, you are exempt from the measles, mumps, and rubella requirements.

If you need catch-up doses, plan ahead. The two-dose measles and varicella series requires at least 28 days between shots, so you cannot complete the form in a single visit. Waiting until the week before your start date to schedule the appointment is the single most common reason new hires get delayed.

Turning the Form In

Once your provider has signed, stamped, and dated the form, deliver the original to your facility director. Do not start working in the classroom or any child-contact area until the director confirms every section is complete. Under § 47.33(b), no staff member “shall be permitted to work in a program” without a valid certificate on file.²

Common reasons a director will reject a form and ask you to go back:

Missing provider license number or agency stamp.
TB test results left blank or recorded without the induration measurement.
Immunization section incomplete, particularly a missing varicella or Tdap entry, since many people assume only MMR is required.
Provider signature missing or undated.

Renewing Every Two Years

The Staff Health Form is not a one-time document. You must repeat the full health examination and submit a new form every two years as a condition of continued employment.¹ Your employer should track expiration dates, but keeping your own calendar reminder is wise. If your form lapses, you can be pulled from child-contact duties until you get a current one.

Facilities must keep your completed form on file for the entire duration of your employment and return it to you upon request when you leave. Chest X-ray reports must be retained for two years after your employment ends.²

Medical Exemptions From the Immunization Requirements

If you have a medical condition that prevents you from receiving a required vaccine, § 47.33(c)(1) allows an exemption based on medical contraindications recognized by the Advisory Committee on Immunization Practices (ACIP) or other nationally recognized evidence-based guidelines.² Your healthcare provider must document the specific contraindication on the form. A vague note that the patient declines is not a medical exemption.

Religious exemptions to staff immunization requirements in NYC childcare settings are a more complex issue and have been subject to evolving policy. If you believe you need a religious accommodation, raise the issue with your employer before your start date so the facility can work through the process.

Who Pays for the Exam

The physical, the TB screening, and any titer bloodwork needed to prove immunity are medical expenses that typically fall on the employee unless your employer has a policy covering them. A basic pre-employment physical generally runs between $100 and $500, and the total can climb if you need catch-up vaccinations or a chest X-ray. Check whether your health insurance covers preventive or occupational exams before scheduling. Many plans cover the physical and TB test at no out-of-pocket cost, while vaccine doses may require a copay. If your employer requires the form as a condition of employment and the facility is covered by OSHA regulations, the employer may be required to cover at least the TB screening component at no cost to you.³ Ask your facility director about reimbursement policies before paying out of pocket.

1
New York City Department of Health and Mental Hygiene. NYC Bureau of Child Care Staff Health Form
2
American Legal Publishing. NYC Rules Title 24 – 47.33 Health; Staff
3
Occupational Safety and Health Administration. The Bloodborne Pathogen Standard and the Enforcement Procedures for TB