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.
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
Practitioner
Date of Examination
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
Signature of Parent
Date of Signature
Vision
Yes No
Lead
Yes No
Hearing
Yes No
Hemoglobin
Yes No
Dental
Yes No
Other
Measurements
Notes
Height
Weight
BMI
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