Child'S Medical Statement
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Ohio 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.
This above named child has been immunized in accordance with the requirements of section 5104.014 of the Ohio
Revised Code (please note any exceptions below).
Signature of Examining Physician/Physician's Assistant/Advanced Practice Registered 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
Exceptions to Immunization requirements pursuant to 5104.014 ORC (please include names of requirement diseases against which the
child has not been immunized and whether it is because the immunization is medically contraindicated, not medically appropriate for the
child’s age, or declined by the parent).
I have declined to have my child immunized against one or more of the diseases required by 5104.014 of the Ohio Revised Code.
Please note disease above and sign.
Signature of Parent
Date of Signature
Optional
Recommended Assessments/Screenings
Vision
Yes
No
Lead
Yes
No
Yes
No
Hearing
Yes
No
Hemoglobin
Dental
Yes
No
Other
Notes
Measurements
Height
Weight
BMI
JFS 01305 (Rev. 12/2016)
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