How to Fill Out California Form LIC 701: Physician’s Report for Child Care

California Form LIC 701 is the pre-admission health evaluation every child needs before starting at a licensed child care center. You fill out Part A, your child’s physician completes Part B after an exam, and the signed form goes to the center within 30 days of your child’s first day.¹

Where to Get the Form

The form is a free PDF on the California Department of Social Services website.² Most centers will also give you a blank copy at enrollment. It’s a single page, front and back, with Part A on top for the parent and Part B below for the medical provider.

Filling Out Part A as the Parent

Part A is short. Fill in your child’s name, date of birth, the name of the child care center, and the days and hours your child will attend. Sign and date it. Your signature authorizes the physician to perform the evaluation and share the results with the center.²

Complete Part A before the appointment, not at the doctor’s office. The provider is expected to review what you entered and indicate on the form that the review took place, so Part A needs to be finished when the exam starts.

What the Provider Completes in Part B

Part B documents the clinical exam. A licensed physician, physician’s assistant, or nurse practitioner can complete and sign it.² The provider works through several areas:

Health concerns the center should know about, including hearing, vision, developmental, language and speech, dental, and behavioral issues.
Allergies, with separate checkboxes for medicine, insect stings, food, and asthma.
Prescribed medications, special routines, and any activity restrictions, so the center can follow the care plan.
Immunization history, either entered on the grid or attached as a California Immunization Record (PM-298).
TB risk factor screening and the outcome.

The provider signs, prints their name and office address, and enters both the date of the physical exam and the date they completed the paperwork. Those two dates can differ if the form is written up after the appointment.

TB Risk Screening

A TB skin test is no longer automatic. The provider screens for risk factors listed on the back of the form, such as a family member with confirmed or suspected TB, birth in or travel to a high-prevalence country, or living with someone recently incarcerated. If none are present, the provider checks the no-risk box and no test is done. If risk factors exist, the provider performs a Mantoux skin test, or a blood test for children four and older, and records the result.²

Immunizations

The grid covers the standard childhood vaccines required by California law: polio (IPV), DTaP, MMR, Hib, hepatitis B, and varicella.³ The provider records the date of each dose. If your child’s PM-298 immunization card is up to date, the provider can attach it rather than copying every date onto the form.

The number of doses required depends on your child’s age at admission. A child admitted between 18 months and 5 years, for example, needs three doses of polio, four DTaP, three hepatitis B, one varicella, and one each of Hib and MMR given on or after the first birthday. Younger children have lower dose counts tied to their vaccination schedule. The full table by age group is on the California Department of Public Health immunization page.⁴

The One-Year Exam Rule

The physical exam documented on Part B cannot be more than one year old when the center receives the form.¹ If you already have a LIC 701 from a prior center and your child is switching, a copy may satisfy the new center as long as the exam date still falls inside that one-year window. If it has expired, you need a fresh physical and a new form.

Submitting the Form to the Center

Deliver the completed original to the child care center. Under state regulations, the center must have a written medical assessment on file either before enrollment or within 30 calendar days of your child’s first day.¹ Many centers will not let a child begin without it, so plan the appointment early. If you cannot get the exam done before the start date, give the center a confirmed appointment date so they can document the delay.

If 30 days passes without a completed assessment, the center at minimum needs a TB test result on file for your child within that same 30-day period.¹ Missing the deadline exposes the center to a licensing citation, so expect persistent follow-up from the facility.

One exception: a child already enrolled in a public or private elementary school does not need a separate LIC 701 at the child care center. The school’s health records satisfy the requirement.¹

Exemptions

If your family adheres to a religious faith that practices healing through prayer or spiritual means, your child is not required to have a medical exam or a completed LIC 701. Instead, you supply information about your child’s health history and sign a written statement accepting full responsibility for the child’s health, refusing a medical examination, and requesting that no medical care be given to the child.¹

That religious exemption applies only to the physical exam. It does not cover immunizations. California eliminated personal belief exemptions for child care immunizations in 2016 under SB 277, and the only remaining exemption is a medical one issued by a licensed physician.⁵ To qualify, your child’s medical circumstances must make immunization unsafe under accepted standards of care, and the physician’s description of the medical basis must align with CDC, ACIP, or AAP guidelines or otherwise be consistent with the standard of care for the specific condition. Medical exemptions are submitted electronically through the California Immunization Registry; a paper letter from a doctor is not accepted.⁶

1
Cornell Law – Legal Information Institute. California Code of Regulations Title 22 101220 – Child’s Medical Assessments
2
California Department of Social Services. Physician’s Report – Child Care Centers
3
California Legislative Information. California Health and Safety Code HSC 120335
4
California Department of Public Health. Shots Required for Child Care/Preschool
5
California Department of Public Health. Exemption FAQs
6
California Health and Human Services. Senate Bill 276 and Senate Bill 714 Vaccinations and Medical Exemptions Questions and Answers