Child Medical Statement
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Ohio Department of Job and Family Services
CHILD MEDICAL STATEMENT
For Child Care Centers and Ty e A Family Child Care Homes
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Child’s Name (print or type)
Date of Birth
This is to certify all of the following:
• I have examined this child and found that he or she is in suitable condition for participation in group care.
• The child has had the age appropriate immunizations recommended by the Ohio Department of Health.
• My office has entered the child's immunizations record below or attached a printed record of the immunizations or found
that this child should be exempt from immunizations for the following reasons: _________________________________
_______________________________________________________________________________________________
List any limitations or health conditions for this child (including allergies, daily medication, dietary restrictions) ____________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Recommended Immunizations (enter month, day, and year)
Vaccines
Dose
1
Dose
2
Dose
3
Dose
4
Dose
5
Diphtheria, Tetanus, Pertussis (DTaP)
Hepatitis B (Hep B)
Haemophilus Influenza type b (HIB)
Measles, Mumps, Rubella (MMR)
Inactivated Polio
Varicella (chicken pox)
Influenza
Pneumococcal Conjugate (PCV)
Rotavirus
Hepatitis A
Other
The immunizations above are recommended by the Centers for Disease Control and Prevention and the Ohio Department of Health.
Recommended Assessments/Screenings:
Vision:
Yes
No
Date: __________
Hearing:
Yes
No
Date: __________
Dental:
Yes
No
Date: __________
Lead:
Yes
No
Date: __________
BMI:
Yes
No
Date: __________
Other: ___________________________________
Signature of examining Physician/Physician's Assistant/Advanced Practice Nurse
Date of Examination
Ohio Administrative Code rules 5101:2-12-37 and 5101-2-13-37 require that this examination be given no
more than twelve months prior to the date of admission to the child care center or type A home.
Name of Physician /Physician's Assistant/Advanced Practice Nurse
Telephone Number
Street Address
City, State and Zip Code
This is a sample form used to meet the requirements of rules 5101:2-12-37 and 5101:2-13-37 of the Administrative Code.
JFS 01305 (Rev. 7/2010)
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