Child Medical Statement
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1Ohio Department of Job and Family Services
CHILD MEDICAL STATEMENT
For Child Care Centers and Type A Family Child Care Homes
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:
Recommended Immunizations (enter month, day, and year)
Recommended Immunizations (enter month, day, and year)
Recommended Immunizations (enter month, day, and year)
Recommended Immunizations (enter month, day, and year)
Recommended Immunizations (enter month, day, and year)
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.
The immunizations above are recommended by the Centers for Disease Control and Prevention and the Ohio Department of Health.
The immunizations above are recommended by the Centers for Disease Control and Prevention and the Ohio Department of Health.
The immunizations above are recommended by the Centers for Disease Control and Prevention and the Ohio Department of Health.
The immunizations above are recommended by the Centers for Disease Control and Prevention and the Ohio Department of Health.
The immunizations above are recommended by the Centers for Disease Control and Prevention and the Ohio Department of Health.
List any limitations or health conditions for this child (including allergies, daily medication, dietary restrictions)
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
Street Address
City, State and Zip Code
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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