DSS Form 2926 is the Staff Health Assessment that South Carolina child care facilities use to document that each worker is physically and mentally fit to care for children. You fill in the identifying section at the top; a licensed health care provider examines you and completes the rest. The signed original goes back to your facility director, who keeps it in your staff file for DSS licensing inspections.1SC Child Care Services. Licensing Requirements
Who Needs One and When
Every director, caregiver, designated emergency contact person, and adult household member at a licensed or registered child care facility in South Carolina needs a completed Form 2926 on file. That covers licensed child care centers, licensed group child care homes, registered family child care homes, and registered church or religious child care centers. In family child care homes, every adult living in the residence needs one, not just the people who directly supervise children.
The assessment has to be completed either within three months before your start date or within your first month of employment. Most directors schedule the appointment before the employee’s first day so nothing slips past that one-month window during a supervisory visit.
What You Fill In Yourself
Download the current version of Form 2926 from the SC Child Care Services provider resources page or pick one up at your local DSS county office.2South Carolina Department of Social Services. South Carolina Department of Social Services Forms and Brochures Print it single-sided so the reverse is available for explanatory notes.
Before your appointment, complete the top section: your full name, your date of birth, and the activity type checkboxes describing what you actually do at the facility. The options cover caring for children, desk work, food preparation, driving vehicles, facility maintenance, and being an adult household member. Check every box that applies. Those checkboxes tell the health care provider what physical demands to evaluate, and an unchecked form does not give the provider enough context to sign off.
Everything below that top block is for the health care provider. Do not fill in the medical history or physical examination yourself. A self-completed form will not pass inspection.
What the Health Care Provider Completes
Bring the form to any licensed health care provider who performs general health evaluations — a physician, nurse practitioner, or physician assistant. The form has three parts.
Part I: Medical History
The provider reviews and documents whether you have any of the following:
- A history of heart attack, angina, or coronary insufficiency
- Epilepsy
- Diabetes
- Current drug or alcohol dependency
- Disabling emotional disorder
- Speech disorder
- Chronic medical conditions or physical impairments requiring activity restrictions or ongoing medication
- Any medical or mental health problem that could interfere with the health of the children or prevent adequate care
A “yes” answer does not automatically disqualify you. The provider uses the reverse side of the form to explain the condition and note whether it affects your ability to perform your role. Under DSS regulations, a staff member with a condition that could be detrimental to children or prevent satisfactory job performance cannot continue working until the health care provider clears them.
Part II: Physical Examination
The provider records the date of the exam and checks three baseline measurements:
- At least 20/20 combined vision (corrected with glasses or contacts if needed)
- Normal hearing
- Normal blood pressure
Part III: Communicable Diseases
The provider certifies whether you have any communicable disease that would prevent you from working in a child care facility. South Carolina’s licensing regulations bar anyone with a communicable disease in a transmissible form, anyone carrying such a disease, or anyone with boils, infected wounds, open sores, or an acute respiratory infection from working in any capacity at a child care center where they could transmit the illness.
The provider closes the form by printing their name, address, and phone number, signing, and dating it. Without that signature block, the form is invalid.
TB Screening and Immunization Review
Form 2926 has a section for TB certification, but the actual tuberculosis screening is documented on a separate form: the DHEC 1420 (School Employee Certificate of Evaluation of TB), under SC DHEC Regulation 61-22. The TB test has to be completed within twelve months before your employment start date, and South Carolina accepts either a tuberculin skin test or an interferon-gamma release assay blood test. Having Form 2926 without a current DHEC 1420 leaves a gap in your file.
The form also asks the provider to confirm whether your immunization status has been reviewed. The licensing regulations recommend a one-time adult dose of Tdap (tetanus, diphtheria, and pertussis) as part of that discussion. The provider checks “yes” or “no” for the immunization review and can add comments about any recommended vaccinations.
After the Form Is Signed
Take the completed original back to your facility director. The form does not get mailed to DSS. It stays at the facility and must be available for review whenever DSS conducts a supervisory visit or licensing inspection.
You need a new Form 2926 at least every four years after the initial assessment. If your health status changes significantly between renewals — a new diagnosis, a hospitalization, or a condition that could affect your work — the regulations require the medical statement to be updated rather than waiting for the four-year cycle. A lapsed health assessment is a compliance deficiency and can trigger a corrective action plan for the facility.
Mistakes That Fail Inspection
- The employee filled out the medical history or physical exam sections instead of the provider.
- No provider signature, or a missing printed name, address, or phone number.
- TB documentation missing because it belongs on the DHEC 1420, not on Form 2926.
- Activity checkboxes at the top left blank.
- Adult household members in a family child care home overlooked.
- The four-year renewal quietly slipped past its expiration date.