The Ohio JFS 01296 form is an essential document required by the Ohio Department of Job and Family Services for child care centers and type A homes. It certifies that an employee has undergone a physical examination and meets specific health requirements before starting employment. Compliance with this form is crucial for adhering to Ohio Administrative Code rules governing child care licensing.
The Ohio JFS 01296 form is a critical document for individuals seeking employment in child care centers and type A homes in Ohio. This form is mandated by specific state regulations that ensure the health and safety of children in care. It requires a thorough physical examination of the prospective employee, which must be conducted no more than 12 months prior to their start date. Key components of the form include verification of the employee’s physical fitness for the role and proof of immunizations against Diphtheria/Tetanus/Pertussis (Tdap) as well as Measles, Mumps, and Rubella (MMR). Notably, employees born on or before December 31, 1956, may provide a history of certain diseases as an alternative to vaccination, with specific guidelines for rubella. The form must be completed and signed by a qualified health care provider, which can include licensed physicians, physician assistants, or certified nurse practitioners. This document is not just a formality; it plays a vital role in maintaining a safe environment for children and complying with Ohio's licensing requirements.
Ohio Department of Job and Family Services
EMPLOYEE MEDICAL STATEMENT
FOR CHILD CARE CENTERS AND TYPE A HOMES
The completion of this form is required by Ohio Administrative Code rules 5101:2-12-25 and 5101:2-13-25 that govern the licensing of child care centers and type A homes. 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
First Day of
Employment
My signature below certifies that I examined the above-named person who is found to be:
1.Physically fit for employment in a facility caring for children
2.Immunized against Diphtheria/Tetanus/Pertussis (Tdap).
(All employees must have verification of being immunized against pertussis by January 2, 2017)
3.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, a physician's assistant, advance practice nurse or a certified nurse practitioner.
This is a sample form that meets the requirements of Ohio Administrative Code rules 5101:2-12-25 and
5101:2-13-25 that govern the licensing of child care centers and type A homes.
JFS 01296 (Rev. 9/2011)
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