JFS 01305 (Rev. 12/2016)
Ohio Department of Job and Family Services
CHILD MEDICAL STATEMENT FOR CHILD CARE
Child’s Name (print or type)
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
Name of Physician/Physician's Assistant/Advanced Practice Nurse/Certified Nurse Practitioner
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.