Ohio Form Jfs 01296 PDF Details

In the realm of child care and early education, ensuring the health and safety of children is paramount. In Ohio, this responsibility is partially addressed through the meticulous implementation of the Ohio JFS 01296 form, an essential document required by the Ohio Department of Job and Family Services. This form serves as a comprehensive employee medical statement, mandating completion for individuals seeking employment within child care centers and Type A homes. Its importance is underscored by regulations stipulated in Ohio Administrative Code rules 5101:2-12-25 and 5101:2-13-25, which outline the licensing prerequisites for such establishments. The form requires a health care professional to affirm that the prospective employee is physically fit for the job and meets specific immunization criteria, including vaccines for Diphtheria/Tetanus/Pertussis (Tdap) and Measles, Mumps, and Rubella (MMR), with certain allowances made for historical disease presence or antibody verification. Signed by a qualified health care provider, the completion of this form, no more than 12 months prior to employment, is a critical step in safeguarding the well-being of children in care settings, reflecting a broader commitment to public health and safety within the sector.

QuestionAnswer
Form NameOhio Form Jfs 01296
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesCurrent EC Medical Form ohio rule 51012 12 25 form

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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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Tips on how to fill in Ohio Form Jfs 01296 stage 1

2. Now that the previous section is done, you need to put in the necessary particulars in Name of Health Care Provider, Signature of Health Care Provider, Phone Number, Date of Examination, This form may be signed by a, and This is a sample form that meets so that you can progress further.

Ohio Form Jfs 01296 completion process outlined (step 2)

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