California Code of Regulations › Title 5 - Education › Division 1 - California Department of Education › Chapter 6 - Certified Personnel › Subchapter 1 - General Provisions › Article 2 - Employment and Dismissal › Section 5504 - Medical Certification Procedures

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The governing board of each school
					 district and the county superintendent of schools office shall provide a
					 pre-employment medical examination form and related information as prescribed
					 in this section to persons being employed for the first time in a California
					 school district or county office in a position requiring certification
					 requirements in accordance with section
					 44839 of
					 the Education Code.
(b) The
					 governing board or office of the county superintendent of schools shall also
					 develop a brief statement of functions involved in the position for which the
					 applicant will be employed and attach it to the medical certification form for
					 the guidance of the physician. Functions should be described in terms of
					 activities which may be performed such as: teaching physical education; being
					 able to readily move about the classroom and playground; climbing flights of
					 stairs or operating mechanical equipment.
(c) The governing board of each school
					 district and the county superintendent of schools office shall use the
					 following medical certificate or a similar certificate developed locally and
					 approved by the California Department of Education:
CERTIFICATE OF MEDICAL EXAMINATION OF APPLICANTS
						FOR FIRST EMPLOYMENT IN A CALIFORNIA SCHOOL DISTRICT OR COUNTY SUPERINTENDENT
						OF SCHOOLS OFFICE
______________________________(Name) School District;
						County Office
Name:
Last
First
Middle
Address:
Street
City
Zip
								Code
To the Physician:
The medical examination required of a person employed in
						a certificated position for the first time in a California School District or
						County Superintendent of Schools Office to determine freedom from any disabling
						disease unfitting the person to instruct or associate with children should be
						evaluated on the basis of the function which will be required of the applicant
						upon employment. A brief description of functions is attached to this
						form.
Disabling disease should be considered in terms
						of:
(1) Evidence of lack of ability to
					 demonstrate average physical and emotional capacity for the functions
					 involved.
(2) Evidence of
					 disability which periodically may disable the individual; for example,
					 rheumatoid arthritis, uncontrolled diabetes, asthma.
(3) Evidence of long term disability which
					 may progressively deteriorate; for example, malignancy, Multiple Sclerosis.
Details
Check Every Item YES
								NO
(Relate to functions to be
								performed)
1.
Is there evidence of disabling disease
								of the musculo-skeletal, cardio-vascular, nervous, gastro-intestinal,
								genito-urinary, endocrine systems? ______
2.
Is there evidence of disabling disease
								affecting vision, hearing or speech? ______
3.
Is there evidence of disabling metabolic
								disease? ______
4.
Is there evidence of infectious disease
								in a communicable stage? ______
5.
Is there evidence of drug dependency
								including alcoholism? ______
6.
Is there evidence of any other disabling
								disease? ______
On the basis of my medical examination on (date)
						____________ the above named individual is free from disabling disease, except
						as noted above, which I believe unfits the individual to instruct, in the
						position for which application is being made, or to associate with
						children.
___________________________
/___________________________
Signature of
								Physician
Date
___________________________
/___________________________
Name of Physician
								(print)
License #
To be returned by the examining physician directly to the
						school district or County Office requesting the
						examination.