MSDE OCC 1204 Medical Evaluation: Filing, TB Step, and Costs

The MSDE OCC 1204 medical evaluation is a one-page Maryland Office of Child Care form that documents you are medically and emotionally fit to work, volunteer, or live in a licensed child care setting. You fill in the top with your name, date of birth, and the facility name, sign the release, then take the form to a physician, certified registered nurse practitioner, or registered physician assistant to complete the clinical section. The signed original goes back to the facility, where it stays in your personnel file for licensing inspectors to review.

Who Needs to Submit One

The requirement reaches different people depending on the type of facility.

At a child care center, every staff member and every support-staff person who will be present while children are in care must have a completed evaluation on file before starting work. Health care professionals who serve only as consultants are exempt.

At a family child care home, the registration applicant, every resident of the home, and any additional adult involved in child care responsibilities each needs an evaluation.¹ Large family child care homes extend the requirement to staff, support staff present during care hours, and volunteers.²

If someone new moves into a family child care home, the provider has to notify the Office of Child Care and submit that person’s evaluation within 15 working days, or at minimum show that an evaluation has been scheduled.¹

Where to Get the Form

The OCC 1204 is a free PDF on the Maryland State Department of Education’s Division of Early Childhood licensing forms page, listed as “Medical Report for Child Care” under the “ALL” category.³ You can also pull it straight from the MSDE file archive.⁴ Without internet access, your regional Office of Child Care will provide a paper copy.

Filling In Your Portion

Print your full name, date of birth, and the name of the child care provider or program where you will work, volunteer, or reside. Below that is an authorization statement releasing the medical information on the form to the Office of Child Care. Sign and date the authorization line. If the person being evaluated is a minor, such as a teenage volunteer, a parent or guardian signs instead.⁴

That’s your entire contribution. The rest belongs to the clinician.

What the Clinician Completes

A licensed physician, certified registered nurse practitioner, or registered physician assistant conducts the evaluation and completes six numbered items.⁴

Item 1 is the date of the evaluation. This date starts the clock for every deadline attached to the form, so make sure it is legible.
Item 2 is tuberculosis screening. Every person needs a risk-and-symptom screening. An actual TB test is required only when the screening indicates it or when a local health officer requires testing. The clinician checks a box confirming the individual is free of communicable tuberculosis.
Item 3 is immunizations. The clinician confirms with a yes-or-no checkbox that they discussed age-appropriate immunizations with you. The form does not ask for a full immunization record.
Item 4 is the fitness recommendation. The clinician checks whether you are “medically and emotionally fit to work, volunteer, or reside in a child care program.” A “No” box requires a written summary of any conditions or medications that could affect your ability to perform in the role.
Item 5 is strength and mobility, applicable to anyone who will work or volunteer rather than only reside. The clinician checks which age groups you can safely care for: 0–2 years, 2–6 years, 7–12 years, or 12–18 years. Infant and toddler care involves more lifting and bending, so the clinician may clear you for older age groups and not younger ones.
Item 6 is the clinician’s signature, printed name and credentials, and office address and phone number, usually by stamp.

The Tuberculosis Step People Miss

The TB section separates the risk screening from the actual TB test. Everyone must complete the screening. A follow-up test only comes into play if the screening flags something or if your local health officer requires testing for child care personnel in your jurisdiction.

When a test is needed, the clinician can use the Mantoux tuberculin skin test, which requires a return visit 48 to 72 hours later to read the result, or an interferon-gamma release assay (IGRA) blood test, which is a single draw. The CDC recommends the blood test for most adults and particularly for anyone who received a BCG vaccine abroad, since the skin test can read falsely positive in those cases.⁵ The form has a blank “Type of Test” field that accepts either method. If the test is positive, the clinician documents the result and any follow-up treatment or chest X-ray that cleared you as non-contagious before checking the “free of communicable tuberculosis” box.

When the Evaluation Has to Be Done By

Deadlines depend on the facility type, and inspectors treat an expired form the same as a missing one.

At child care centers and large family child care homes, the evaluation must be completed within 6 months before you begin work.² At family child care homes, it must be completed within 12 months before the date of application for registration.¹

An existing evaluation can sometimes travel with you. For large family child care homes, an evaluation transfers from another home or from a licensed center as long as it was completed within the previous 24 months.² If you are moving from one facility to another, ask whether your current form will carry over before paying for a new exam.

Renewal cycles after the first evaluation:

Large family child care homes: every 2 years from the date of the previous evaluation.²
Family child care homes: every 24 months after the date of continuing registration.¹
Child care centers: every 5 years from the date of the previous evaluation.

Where to Turn In the Completed Form

The OCC 1204 does not go to the state. Hand the signed original to the facility administrator or home provider once the clinician has filled it out. The facility stores it as part of personnel records and must make it available to agency representatives on request. Licensing inspectors can visit without advance notice at least once every 12 months and may review records during any visit. Facilities must keep personnel records, including the medical evaluation, for at least 2 years after an individual’s last day.⁶

Keep a copy for yourself before handing over the original. If you change jobs within the renewal window, that copy is how you prove the exam date to the next facility.

What Happens If the Form Is Missing or Expired

If an inspector finds a staff member’s evaluation missing, expired, or incomplete, the facility faces enforcement action. Minor compliance problems typically start with a written warning that gives the provider time to fix the issue.⁷ More serious or repeated violations can trigger intermediate sanctions such as capacity limits, civil penalties of up to $1,000 per violation (capped at $5,000 per civil action, with each day the violation continues counting as a separate offense), or in cases that threaten children’s health, safety, or welfare, suspension for up to 60 days or revocation.⁸ One missing form rarely causes a suspension on its own, but it rarely stays alone either; inspectors who find one gap usually look harder at the rest.

What the Exam Costs

The form is free. The exam itself is not. A basic employment physical typically runs between $50 and $350, and a TB skin test is often inexpensive or free at a local health department. Maryland regulations do not say whether the employer or the individual pays, so settle that question with the facility before you schedule the appointment. Some operators cover it as a hiring expense; others expect candidates to pay their own way.

If your employer requires the screening during your workday, federal wage rules treat the time spent waiting for and completing the exam as compensable work time. For an exam on a day off, the time is likely compensable if the exam is necessary for you to perform your job.

If the Clinician Marks You “Not Fit” or Limits Your Age Groups

A “No” on Item 4, or a limited set of checked boxes on Item 5, does not automatically disqualify you. Under the Americans with Disabilities Act, employers must consider reasonable accommodations that would let a qualified person with a disability perform the essential functions of the position. In a child care setting that might look like job restructuring, a modified schedule, or assignment to age groups that match your physical capabilities.⁹ The employer is only excused from accommodating you if doing so would cause undue hardship to the operation.

1
Library of Maryland Regulations. Subtitle 15 Family Child Care
2
Library of Maryland Regulations. COMAR 13A.18.06.04 – Staff Health
3
Maryland State Department of Education. Licensing Forms
4
Maryland State Department of Education. OCC 1204 Medical Evaluation for Child Care
5
Centers for Disease Control and Prevention. TB Prevention in Health Care Settings
6
Library of Maryland Regulations. COMAR 13A.18.03.05 – Staff Records
7
Library of Maryland Regulations. COMAR 13A.16.17.08
8
Legal Information Institute. COMAR 13A.16.17.08 – Penalties
9
U.S. Equal Employment Opportunity Commission. Enforcement Guidance on Reasonable Accommodation and Undue Hardship Under the ADA