Child Medical Statement for Child Care (JFS 01305)

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:

The above named child has been immunized against the diseases listed above. If an immunization is medically contraindicated or not medically appropriate for the child’s age, note any exceptions by listing the specific immunization(s):

Initials of Examining Health Care Practitioner

Date

Section C - To be completed by the child's parent ONLY IF WAIVING AN IMMUNIZATION(S):

I have declined to have my child immunized for reasons of conscience, including religious convictions against all of the diseases listed above or against the following disease(s):

Signature of Parent

Date

CHILD MEDICAL STATEMENT FOR CHILD CARE

Section A- EXAMINATION

IMMUNIZATION (Complete ONLY ONE SECTION below)

Section B - To be completed by the EXAMINING HEALTH CARE PRACTITIONER:

Section C - To be completed by the child's parent ONLY IF WAIVING AN IMMUNIZATION(S):