Child Medical Statement For Child Care - Ohio Department Of Job And Family Services
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1Ohio Department of Job and Family Services
CHILD MEDICAL STATEMENT FOR CHILD CARE
Child’s Name (print or type)
Date of Birth
This above named child has been examined, the immunization status recorded, and the child is in suitable condition for participation
in group care.
Signature of Examining Physician/Physician's Assistant/Advanced Practice Nurse/Certified Nurse
Date of Examination
Practitioner
Name of Physician/Physician's Assistant/Advanced Practice Nurse/Certified Nurse Practitioner
Telephone Number
Street Address
City, State and Zip Code
ATTACH A COPY OF THE CHILD'S IMMUNIZATION RECORD WITH DATES OF DOSES OF ALL IMMUNIZATIONS
PHYSICIAN /PHYSICIAN'S ASSISTANT/ADVANCED PRACTICE
NURSE/CERTIFIED NURSE PRACTITIONER COMPLETES
check all that apply for each disease
Medically Contraindicated/
Immunized
In Process of Immunization
Diseases for Immunization
Not Age Appropriate
Chicken pox
Diphtheria
Haemophilus influenzae type b
Hepatitis A
Hepatitis B
Influenza
Seasonal Vaccine Not Available
Measles
Mumps
Pertussis
Pneumococcal disease
Poliomyelitis
Rotavirus
Rubella
Tetanus
I have declined to have my child immunized against one or more of the diseases required by 5104.014 of the Ohio Revised Code. Initial beside the
disease(s) being declined above and sign below.
Signature of Parent
Date of Signature
Recommended Assessments/Screenings
Vision
Yes
No
Lead
Yes
No
Hearing
Yes
No
Hemoglobin
Yes
No
Dental
Yes
No
Other
Notes:
Measurements:
Height
Weight
BMI
JFS 01305 (Rev. 6/2015)
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