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LIC 503: Health Screening Report - Facility Personnel
By Sevana Care · Checked against cdss.ca.gov and Title 22 on
- When it is due
- A physician's health screening must be performed "not more than six (6) months prior to or seven (7) days after employment or licensure" [4].The form gives the same window around employment for an RCFE [1]. Neither the rule nor the form sets a repeat schedule [4][1].
- Who fills it out
- The form says the health appraisal "is to be completed by or under the direction of a physician" [1].The rule asks for a report of each screening "signed by the examining physician" [4]. The person screened signs a release of medical information [1].
- Where it is kept
- In the person's personnel record.Section 87412(a)(11) lists "A health screening as specified in Section 87411" in that record, and § 87412(g) keeps personnel records at the facility, or at a central administrative location if they are readily available to licensing at the facility [5]. CDSS lists LIC 503 under "Personnel Records" [3].
LIC 503 is the California Department of Social Services (CDSS) Health Screening Report - Facility Personnel. Title 22 § 87411(f) says all RCFE personnel, "including the licensee and administrator," must be in good health, and that good health is "verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician" [4]. The section asks for "a report" of each screening and names no form [4]. CDSS lists LIC 503 as the RCFE record for it [3], and its application instructions list LIC 503 for a new license [6].
Who fills it out
The form says: "This health appraisal is to be completed by or under the direction of a physician" [1]. Three texts word the signer differently:
- Title 22 § 87411(f): the screening is "performed by a physician," and the report is "signed by the examining physician" [4].
- The form: "by or under the direction of a physician" [1].
- CDSS's application instructions: "The LIC 503 must be signed and dated by a qualified medical professional" [6]. The same instructions say the licensing agency "will NOT accept photocopied signatures on this form" [6].
The person screened signs below "I HEREBY AUTHORIZE THE RELEASE OF MEDICAL INFORMATION CONTAINED IN THIS REPORT." The form calls that signer the "Applicant/Licensee or Employee" [1]. The physician's side of page 2 has a name line with "Physician's Stamp" and "Health Screening by: (Original Signature)" with a telephone number and date [1]. The form does not say who fills in the facility name, address and duty statement at the top.
The form says the screening covers "All personnel, including applicant, licensee or employed staff" of RCFEs and three other facility types [1]. Section 87411(f) covers "All personnel, including the licensee and administrator" [4].
When it is due
The window. Section 87411(f): good physical health "shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure" [4]. The form puts it this way for an RCFE: "within seven (7) days after employment or not more than six (6) months prior to employment." For the other facility types it names, the form says "not more than one (1) year prior to employment" [1].
At application. CDSS's application instructions say: "Health screening, at time of application, must be less than six months old for applicants for Residential Care Facilities for the Elderly and one year old for all other categories." They also say one form is required for the applicant or designee and one for the administrator [6].
A health exam already on file. The same instructions say: "If the applicant has other licensed facilities, or the administrator worked at another facility with the same licensee and there is an exam on file, a new health exam is not required unless there are obvious health problems" [6].
No repeat schedule. Section 87411(f) gives the window around employment or licensure and no later dates. The form gives none either [4][1]. Neither text sets a TB retest period. Section 87411(c) requires initial and annual training, and § 87412(c) sets hours for it. Neither covers health screenings [4][5].
Where it is kept
Section 87412(a) requires a personnel record for the licensee, the administrator and each employee, and item (a)(11) puts "A health screening as specified in Section 87411" in it [5]. Section 87412(g): "All personnel records shall be maintained at the facility." The licensee may use a central administrative location "provided that they are readily available to the licensing agency at the facility" [5].
CDSS's list of RCFE records puts "Health Screening Report/Tuberculosis (TB) Clearance (LIC 503)" under "Personnel Records." The list is dated 4/05 [3]. Section 87412(f) makes personnel records available to the licensing agency "to inspect, audit, and copy upon demand during normal business hours" [5].
How long to keep it. Section 87412(h): "All personnel records shall be retained for at least three (3) years following termination of employment" [5]. Section 87412 does not name LIC 503 [5].
What the record must show
Rule. The report of each screening "shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents" [4]. Section 87412(a)(12) also lists "Hazardous health conditions documents as specified in Section 87411" in the personnel record [5].
Form, page 1 [1]:
- The facility name and address, and the person's name, age and position title.
- The type of facility, workdays per week and work hours per day.
- A duty statement.
- "TYPES OF PERSONS SERVED," with boxes for infants, adults, elderly, children and other groups.
- The release of medical information, signed and dated.
Form, page 2 [1]:
- "Evaluation of general health."
- "Evaluation of ability to perform work described in the above duty statement."
- "Note any health condition that would create a hazard to persons in care or other personnel."
- The date of the TB test, Positive or Negative, and the "Action Taken (If Positive)."
- The date of the health screening, the physician's name, and the physician's signature, telephone and date.
The TB test. CDSS's application instructions say: "The Tuberculosis (TB) test portion of the form must be filled out, including result, or a separate test verification is needed" [6].
Volunteers. Section 87411(f): "A signed statement shall be obtained from each volunteer affirming that he/she is in good health." Section 87412(b) lists "A health statement as specified in Section 87411(f)" and "Health screening documents as specified in Section 87411(f)" for volunteers [4][5]. The form speaks of "personnel," "applicant, licensee or employed staff," and does not mention volunteers [1]. CDSS's list has a separate line: "TB clearance and 'good health' statement from volunteers" [3]. None of these names a form for volunteers.
Staff who may not work. Section 87411(f): "Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties" [4].
Questions
Does an RCFE have to use LIC 503?
Section 87411(f) asks for a report of each screening and names no form [4]. CDSS lists LIC 503 under RCFE "Personnel Records" [3], and marks it "Required" for a license application [6].
Does the screening repeat every year?
Section 87411(f) and the form give the window around the start of employment or licensure and no repeat schedule [4][1].
Who has to sign: a physician or another medical professional?
The sources word it differently. Title 22 § 87411(f) says "physician," the form says "by or under the direction of a physician" and CDSS's application instructions say "qualified medical professional" [4][1][6].
Is anyone excused from LIC 503?
CDSS's application instructions say the form "is not required, under certain circumstances, of persons who are adherents of a well-recognized church relying solely upon prayer or spiritual means of healing." The facility must still "present satisfactory evidence to the licensing agency that individuals are free from any communicable disease," as "a written statement from a practitioner recognized by this religion for the purpose of healing" [6]. Section 87411(f) states no such exception [4].
Is LIC 503 only for RCFEs?
No. The form names RCFEs, Community Care Facilities, Residential Care Facilities for the Chronically Ill and Child Care Facilities [1].
Is LIC 503 MFHV the same form?
No. CDSS lists "LIC 503 MFHV (6/26)" as a separate form for a Medical Foster Home for Veterans. Its screening window is "seven (7) days after employment or not more than one year prior to employment," and it is completed by or under a "licensed medical professional acting within their scope of practice" [2][7].
How Sevana Care keeps this record
Tired of digging through a binder for a TB test? Every person on your team gets their own personnel file in Sevana Care, with a place for the health screening and the TB test. Both are required, and each shows Missing until it is filed. When someone leaves, their page reads "Former staff · personnel file kept for 3 years."
We don't fill out the LIC 503. Take a look in the sample home.
More in Staff and background checks
Sources
- CDSS, LIC 503 (6/24), Health Screening Report - Facility Personnel (PDF)
- CDSS, Forms and Publications (I-L)
- CDSS, LIC 311F (4/05), Records To Be Maintained At The Facility, Residential Care Facility For The Elderly (PDF)
- California Code of Regulations, Title 22, § 87411, Personnel Requirements--General (Westlaw)
- California Code of Regulations, Title 22, § 87412, Personnel Records (Westlaw)
- CDSS, LIC 281 (11/25), Application Instructions for a Facility License (PDF)
- CDSS, LIC 503 MFHV (6/26), Health Screening Report - Facility Personnel MFHV (PDF)