Ohio Form Jfs 01296 PDF Details

Are you looking to apply for certain Ohio benefits, such as unemployment or food assistance? If yes, then you may be in need of a form that is required for the application process. The Ohio Form JFS 01296 is an important document that must be filled out and submitted in order to go through the steps of receiving these state benefits. In this blog post, we will discuss what this form is and why it’s necessary, walk through how to fill it out correctly, and address any potential questions or confusion surrounding the completion of this document. Let's get started!

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

Form Preview Example

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)

How to Edit Ohio Form Jfs 01296 Online for Free

With the help of the online PDF editor by FormsPal, you can easily complete or edit Ohio Form Jfs 01296 right here. To make our editor better and less complicated to utilize, we constantly implement new features, with our users' feedback in mind. To get started on your journey, take these simple steps:

Step 1: Open the form inside our tool by clicking the "Get Form Button" above on this page.

Step 2: This editor gives you the capability to work with nearly all PDF documents in a variety of ways. Enhance it by writing personalized text, adjust existing content, and include a signature - all manageable in no time!

This PDF requires particular information to be typed in, thus make sure you take whatever time to enter exactly what is asked:

1. The Ohio Form Jfs 01296 will require specific information to be typed in. Ensure that the following blanks are complete:

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)

Those who use this form frequently get some points incorrect while filling in Name of Health Care Provider in this area. Remember to reread everything you type in here.

Step 3: Reread the information you've typed into the blank fields and click the "Done" button. Make a free trial plan at FormsPal and gain direct access to Ohio Form Jfs 01296 - download or modify from your FormsPal cabinet. We don't share the information you provide while working with documents at our site.

Ohio Form Jfs 01296 isn’t the one you’re looking for?

Related Documents