Caring for Our Children (CFOC)

Chapter 1: Staffing

1.7 Staff Health

1.7.0 Pre-Employment and Ongoing Adult Health Appraisals, Including Immunization

Frequently Asked Questions/CFOC Clarifications


Date: 02/17/2012

Topic & Location:
Chapter 1
Staffing Pre-Employment and Ongoing Adult Health Appraisals, Including Immunization

This standard title suggests that something will be said about ongoing adult health appraisals and immunization, but the standard only addresses prechild contact requirements. Further, isn’t a “pre-employment” health appraisal not permitted before a job offer is made per the Equal Employment Opportunity Commission regulations? Shouldn’t there be a requirement for a health appraisal whenever someone has a change in position or role that has physical requirements and at least at the intervals recommended by whoever makes credentialed recommendations for such services for adults?

The intention of this standard is that a pre-employment health appraisal of all paid and volunteer staff should be conducted and that ongoing health appraisals should be required based on the employee’s primary health care provider’s recommendation and/or if there is a change in the physical requirements of the position or role. "Pre-employment" does not mean pre-hire. Often a job offer is issued and a pre-employment screening is then required prior to the assigned employment date.

All paid and volunteer staff members should have a health appraisal before their first involvement in child care work. The appraisal should identify any accommodations required of the facility for the staff person to function in his or her assigned position.

Health appraisals for paid and volunteer staff members should include:

  1. Physical exam;
  2. Dental exam;
  3. Vision and hearing screening;
  4. The results and appropriate follow up of a tuberculosis (TB) screening, using the Tuberculin Skin Test (TST) or IGRA (interferon gamma release assay), once upon entering into the child care field with subsequent TB screening as determined by history of high risk for TB thereafter;
  5. A review and certification of up-to-date immune status per the current Recommended Adult Immunization Schedule found in Appendix H, including annual influenza vaccination and up to date Tdap;
  6. A review of occupational health concerns based on the performance of the essential functions of the job.

All adults who reside in a family child care home who are considered to be at high risk for TB, should have completed TB screening (1) as specified in Standard Adults who are considered at high risk for TB include those who are foreign-born, have a history of homelessness, are HIV-infected, have contact with a prison population, or have contact with someone who has active TB.

Testing for TB of staff members with previously negative skin tests should not be repeated on a regular basis unless required by the local or state health department. A record of test results and appropriate follow-up evaluation should be on file in the facility.

Caregivers/teachers need to be physically and emotionally healthy to perform the tasks of providing care to children. Performing their work while ill can spread infectious disease and illness to other staff and the children in their care (2). Under the Americans with Disabilities Act (ADA), employers are expected to make reasonable accommodations for persons with disabilities. Under ADA, accommodations are based on an individual case by case situation. Undue hardship is defined also on a case by case basis. Accommodation requires knowledge of conditions that must be accommodated to ensure competent function of staff and the well-being of children in care (3).

Since detection of tuberculosis using screening of healthy individuals has a low yield compared with screening of contacts of known cases of tuberculosis, public health authorities have determined that routine repeated screening of healthy individuals with previously negative skin tests is not a reasonable use of resources. Since local circumstances and risks of exposure may vary, this recommendation should be subject to modification by local or state health authorities.

Child care facilities should provide the job description or list of activities that the staff person is expected to perform. Unless the job description defines the duties of the role specifically, under federal law the facility may be required to adjust the activities of that person. For example, child care facilities typically require the following activities of caregivers:
  1. Moving quickly to supervise and assist young children;
  2. Lifting children, equipment, and supplies;
  3. Sitting on the floor and on child-sized furniture;
  4. Washing hands frequently;
  5. Responding quickly in case of an emergency;
  6. Eating the same food as is served to the children (unless the staff member has dietary restrictions);
  7. Hearing and seeing at a distance required for playground supervision or driving;
  8. Being absent from work for illness no more often than the typical adult, to provide continuity of caregiving relationships for children in child care.

Healthy Young Children: A Manual for Programs, from the National Association for the Education of Young Children (NAEYC), provides a model form for an assessment by a health professional. See also Model Child Care Health Policies, from NAEYC and from the American Academy of Pediatrics (AAP).

Concern about the cost of health exams (particularly when many caregivers/teachers do not receive health benefits and earn minimum wage) is a barrier to meeting this standard. When staff members need hepatitis B immunization to meet Occupational Safety and Health Administration (OSHA) requirements (4), the cost of this immunization may or may not be covered under a managed care contract. If not, the cost of health supervision (such as immunizations, dental and health exams) must be covered as part of the employee’s preparation for work in the child care setting by the prospective employee or the employer. Child care workers are among those for whom annual influenza vaccination is strongly recommended.

Facilities should consult with ADA experts through the U.S. Department of Education funded Disability and Business Technical Assistance Centers (DBTAC) throughout the country. These centers can be reached by calling 1-800-949-4232 (callers are routed to the appropriate region) or by accessing regional center’s contacts directly at http://adata

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home
RELATED STANDARDS Staff Health Guidelines for Return to Work On-Site Occupational Hazards Immunization Documentation Unimmunized/Underimmunized Children Immunization of Staff Measures for Detection, Control, and Reporting of Tuberculosis Attendance of Children with Latent Tuberculosis Infection or Active Tuberculosis Disease
Appendix E: Child Care Staff Health Assessment
  1. Baldwin, D., S. Gaines, J. L. Wold, A. Williams. 2007. The health of female child care providers: Implications for quality of care. J Comm Health Nurs 24:1-7.
  2. Keyes, C. R. 2008. Adults with disabilities in early childhood settings. Child Care Info Exchange 179:82-85.
  3. Occupational Safety and Health Administration. 2008. Bloodborne pathogens. Title 29, pt. 1910.1030. _id=10051.
  4. Centers for Disease Control and Prevention. 2015. Recommended adult immunization schedule – United States, 2015.