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JFS 01305 (Rev. 10/20 21) Ohio Department of Job and Family Services CHILD MEDICAL STATEMENT FOR CHILD CARE Child’s Name (print or type) Date of Birth Note: Section s A and B must be completed by the examining Health Care Practitioner (Physician/Physician's Assistant/Advanced Practice Registered Nurse/Certified Nurse Practitioner):
The JFS 01305 "Child Medical Statement for Child Care," the sample form, has been revised to comply with the requirements in section 5104.014 ORC. Implementation: Any medical statement dated on or after March 19, 2015 will need to include the new immunization requirements.
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.
JFS 01305 (Rev. 6/2015) 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.
JFS 01305, "Child's Medical Statement," is a sample form that may be used to provide the required documentation regarding a child's medical examination. Shading has been added to the Varicella (chicken pox) and the Hepatitis A "Dose 3" boxes, as these immunizations must be given in two doses.
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.
JFS 01305 "Child Medical Statement for Child Care" - this sample form has been revised to comply with the requirements in section 5104.014 ORC. Implementation: Any medical statement dated on or after March 19, 2015 will need to include the new immunization requirements.
CHILD MEDICAL STATEMENT FOR CHILD CARE. ATTACH A COPY OF THE CHILD'S IMMUNIZATION RECORD INCLUDING DATES (MM/DD/YYYY FORMAT) OF DOSES OF ALL IMMUNIZATIONS. JFS 01305 (Rev. 10/2021)
CHILD MEDICAL STATEMENT FOR CHILD CARE. ATTACH A COPY OF THE CHILD'S IMMUNIZATION RECORD INCLUDING DATES (MM/DD/YYYY FORMAT) OF DOSES OF ALL IMMUNIZATIONS. JFS 01305 (Rev. 10/2021)