JFS 01305 (Rev. 10/202 1) Ohio Department of Job and Family Services CHILD MEDICAL STATEMENT FOR CHILD CARE. Child’s Name (print or type) Date of Birth . Note: Sections A and B must be completed by the examining Health Care Practitioner (Physician/Physician's Assistant/Advanced Practice Registered Nurse/Certified NursePractitioner ):

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JFS 01305 (Rev. 12/2016) 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.

To search for a state form, use the Ohio Department of Job and Family Services Forms Central. In order to assist us in processing your documents, please put your name and social security or case number on all documents you submit. The easiest and most efficient way to submit document is by visiting your local library.

CHILD MEDICAL STATEMENT FOR CHILD CARE - storage.snappages.site

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.

ATTACH A COPY OF THE CHILD'S IMMUNIZATION RECORD INCLUDING DATES (MM/DD/YYYY FORMAT) OF DOSES OF ALL IMMUNIZATIONS. Chicken pox, Diphtheria, …

JFS 01305 (Rev. 6/2015) Author: Daniel Hurley Created Date: 5/28/2015 12:15:05 PM ...

JFS 01305 (Rev. 10/2021) Ohio Department of Job and Family Services CHILD MEDICAL STATEMENT FOR CHILD CARE Child’s Name (print or type) Date of Birth Note: Sections A and B must be completed by the examining Health Care Practitioner (Physician/Physician's Assistant/Advanced Practice Registered Nurse/Certified Nurse Practitioner):

JFS 01305 (Rev. 10/2021) Muskingum University Center for Child Development 740-826-8351 Attn: Sharon Price