The Children’s Place Learning Academy

child medical statement form

child medical statement

CHILD MEDICAL STATEMENT FOR CHILD CARE

Ohio Department of Job and Family Services

Note: Sections A and B must be completed by the examining Health Care Practitioner (Physician/Physician’s Assistant/Advanced Practice Registered Nurse/Certified Nurse Practitioner):
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Section A- EXAMINATION

  • The above named child has been examined.
  • The above named child is in suitable condition for participation in group care (i.e. free of infectious disease, mentally and physically fit to be in group care).
  • The above named child does not have allergies OR is allergic to the following (please list in space below):
Optional: Measurements and Recommended Assessments/Screenings
ATTACH A COPY OF THE CHILD'S IMMUNIZATION RECORD INCLUDING DATES (MM/DD/YYYY FORMAT) OF DOSES OF ALL IMMUNIZATIONS.
IMMUNIZATION(Complete ONLY ONE SECTION below)
Section 5104.014 of the Ohio Revised Code requires immunizations against the following diseases:
Chicken pox, Diphtheria, Haemophilus influenzae type b, Hepatitis A, Hepatitis B, Influenza, Measles, Mumps, Pertussis, Pneumococcal disease, Poliomyelitis, Rotavirus, Rubella and Tetanus.
Section B - To be completed by the EXAMINING HEALTH CARE PRACTITIONER:
If an immunization is medically contraindicated or not medically appropriate for the child’s age, note any exceptions by listing the specific immunization(s):
Section C - To be completed by the child's parent ONLY IF WAIVING AN IMMUNIZATION(S):

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