Ohio Department of Job and Family Services
EMPLOYEE MEDICAL STATEMENT FOR CHILD CARE
The physical examination and completion of this form must occur no more than 12 months prior
to the first day of employment.
To be completed by the Health Care Provider
My signature below certifies that I examined the above-named person who is found to be
Physically fit for employment in a facility caring for children
Immunized against Diphtheria/Tetanus/Pertussis (Tdap)
(All employees must have verification of being immunized against pertussis by January 1, 2018)
Immunized against Measles, Mumps and Rubella (MMR)
(Except that for a person born on or before December 31, 1956, a history of mumps or measles
disease may be substituted for the vaccine. A history of rubella disease shall not be substituted for
rubella vaccine. Only a laboratory test demonstrating detectable rubella antibodies shall be
accepted in lieu of rubella vaccine).
Name of Health Care Provider* (Please Print)
Signature of Health Care Provider*
*This form may be signed by a licensed physician, physician's assistant, advanced practice registered
nurse, certified midwife or certified nurse practitioner.
JFS 01296 (Rev. 12/2016)