Ohio Department of Job and Family Services
The physical examination and completion of this form must occur no more than 12 months prior
to the first day of employment.
Name of Employee
Home Address
City, State, Zip
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)
Street Address
City, State, Zip
Phone Number
Signature of Health Care Provider*
Date of Examination
*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)
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