Homepage Blank Ohio Jfs 01296 PDF Form
Content Overview

The Ohio JFS 01296 form, officially known as the Employee Medical Statement for Child Care Centers and Type A Homes, plays a crucial role in ensuring the health and safety of children in care settings. This form is mandated by specific Ohio Administrative Code rules that govern the licensing of child care facilities. It requires a thorough physical examination of potential employees, which must occur within 12 months prior to their first day of work. The form captures essential information, including the employee’s name, address, and employment start date. It confirms that the individual is physically fit for employment and outlines necessary immunizations against diseases such as Diphtheria, Tetanus, Pertussis (Tdap), and Measles, Mumps, and Rubella (MMR). Notably, certain exceptions apply based on the employee's birthdate regarding the MMR vaccine. The form must be completed and signed by a qualified health care provider, which can include a physician, physician's assistant, or nurse practitioner. By adhering to these requirements, child care centers and homes can help ensure a safe environment for the children they serve.

Document Preview

JFS 01296 (Rev. 9/2011)
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.

Form Specifications

Fact Name Details
Form Purpose The Ohio JFS 01296 form is an Employee Medical Statement required for child care centers and Type A homes.
Governing Laws This form is governed by Ohio Administrative Code rules 5101:2-12-25 and 5101:2-13-25.
Examination Timeline The physical examination must occur no more than 12 months before the employee's first day of work.
Immunization Requirements Employees must be immunized against Diphtheria/Tetanus/Pertussis (Tdap) and Measles, Mumps, and Rubella (MMR).
Age Exceptions For those born on or before December 31, 1956, a history of mumps or measles may replace the MMR vaccine.
Signature Requirements The form must be signed by a licensed physician, physician's assistant, advance practice nurse, or certified nurse practitioner.
Revision Date The current version of the form is JFS 01296 (Rev. 9/2011).

Ohio Jfs 01296: Usage Guidelines

Filling out the Ohio JFS 01296 form is a straightforward process that ensures compliance with state regulations for child care employment. After completing the form, it will need to be submitted to the appropriate authorities as part of the licensing process.

  1. Start by entering the Name of Employee at the top of the form.
  2. Next, fill in the Home Address of the employee.
  3. Indicate the First Day of Employment in the designated space.
  4. The health care provider must complete the next section. They will need to certify the employee's health status. This includes confirming that the employee is:
    • Physically fit for employment in a child care facility.
    • Immunized against Diphtheria/Tetanus/Pertussis (Tdap).
    • Immunized against Measles, Mumps, and Rubella (MMR). Note any exceptions for those born on or before December 31, 1956.
  5. Have the health care provider print their Name in the appropriate space.
  6. Fill in the Street Address, City, State, and Zip of the health care provider.
  7. Enter the Phone Number of the health care provider.
  8. Sign the form in the section labeled Signature of Health Care Provider.
  9. Finally, include the Date of Examination at the bottom of the form.

Your Questions, Answered

What is the Ohio JFS 01296 form?

The Ohio JFS 01296 form is an Employee Medical Statement required for individuals seeking employment in child care centers and Type A homes. This form ensures that employees meet health standards set by the Ohio Administrative Code.

Who needs to complete the JFS 01296 form?

Any employee who will work in a child care center or a Type A home in Ohio must complete this form. It is essential for ensuring that all staff members are physically fit to care for children.

When must the JFS 01296 form be completed?

The form must be completed no more than 12 months prior to the employee's first day of work. This time frame ensures that the health information is current and relevant.

What health requirements are included in the JFS 01296 form?

The form requires verification of the employee's physical fitness for work, as well as proof of immunizations against Diphtheria/Tetanus/Pertussis (Tdap) and Measles, Mumps, and Rubella (MMR). Specific exceptions apply for individuals born on or before December 31, 1956, regarding MMR vaccination.

Who can sign the JFS 01296 form?

The form must be signed by a licensed physician, a physician's assistant, an advanced practice nurse, or a certified nurse practitioner. This ensures that a qualified health professional has assessed the employee's health status.

What happens if an employee does not submit the JFS 01296 form?

Failure to submit the JFS 01296 form can result in the inability to work in a child care setting. Compliance with this requirement is crucial for maintaining licensing standards.

Is there a specific format for the information provided on the JFS 01296 form?

Yes, the form requires specific details such as the employee's name, home address, first day of employment, and the health care provider's information. This structured format helps ensure all necessary information is collected efficiently.

Can the JFS 01296 form be submitted electronically?

The submission process may vary by employer. It is advisable to check with the specific child care center or Type A home regarding their preferred method of submission, whether electronic or paper format.

What should I do if I have questions about filling out the JFS 01296 form?

If you have questions, it is best to consult with your health care provider or the administrative staff at your child care facility. They can provide guidance on completing the form accurately.

Where can I find the JFS 01296 form?

The JFS 01296 form can typically be found on the Ohio Department of Job and Family Services website or through your child care center's administrative office. Ensure you are using the most current version of the form.

Common mistakes

  1. Failing to complete the form within the required timeframe. The physical examination must occur no more than 12 months before the first day of employment.

  2. Not providing accurate personal information. Ensure the employee's name and home address are correctly entered to avoid processing delays.

  3. Overlooking immunization records. Employees must be immunized against Diphtheria/Tetanus/Pertussis (Tdap) and Measles, Mumps, and Rubella (MMR). Verification of these immunizations is crucial.

  4. Ignoring age-specific requirements. For individuals born on or before December 31, 1956, a history of mumps or measles disease can substitute for the vaccine, but this does not apply to rubella.

  5. Neglecting to include the health care provider's information. The form must be signed by a licensed physician, physician's assistant, advance practice nurse, or certified nurse practitioner, along with their contact details.

  6. Not signing the form. The health care provider's signature is essential for the form to be valid and accepted.

Documents used along the form

When dealing with the Ohio JFS 01296 form, which is essential for ensuring that employees in child care settings are medically fit, several other documents may be required to support compliance with state regulations. Each of these documents plays a critical role in the overall process of hiring and maintaining a safe environment for children in care. Below is a list of additional forms and documents often used in conjunction with the Ohio JFS 01296 form.

  • Child Care Center License Application: This document is necessary for obtaining a license to operate a child care center. It includes information about the facility, its staff, and compliance with safety and health regulations.
  • Employee Background Check Consent Form: Before hiring, employers must conduct background checks on potential employees. This form allows the employer to obtain necessary information regarding the applicant's criminal history and suitability for working with children.
  • Immunization Records: These records provide proof that employees have received the required vaccinations, such as Tdap and MMR. They are crucial for ensuring the health and safety of children in the facility.
  • Health History Questionnaire: This form collects detailed information about an employee’s medical history, including any chronic conditions or allergies that may affect their ability to work in a child care setting.
  • Emergency Contact Information Form: This document lists emergency contacts for employees, ensuring that there is a plan in place in case of an emergency during work hours.

Each of these documents complements the Ohio JFS 01296 form, creating a comprehensive approach to employee health and safety in child care environments. By understanding the purpose of each document, employers can better navigate the requirements for licensing and ensure a safe, compliant operation.

Similar forms

The Ohio JFS 01296 form serves as an essential document for ensuring the health and safety of employees in child care settings. Several other documents share similarities with this form, particularly in their purpose and the information they require. Here’s a look at seven such documents:

  • Employee Health Assessment Form: Similar to the JFS 01296, this form is used to evaluate the health status of employees in various sectors. It typically requires a physical examination and verification of immunizations.
  • Child Care Center Licensing Application: This document is crucial for obtaining a license to operate a child care center. It often includes health assessment requirements for staff, ensuring compliance with safety regulations.
  • School Employee Health Form: Like the JFS 01296, this form assesses the health of school employees. It verifies physical fitness and immunization status, particularly for those working with children.
  • Pre-Employment Medical Examination Form: This document is used by employers across various industries to confirm that potential employees are physically fit for their roles. It includes similar health assessment criteria as the JFS 01296.
  • Immunization Record: This record tracks an individual's vaccination history. It serves as proof of immunization against diseases, paralleling the immunization requirements outlined in the JFS 01296.
  • Health Clearance Certificate: Often required for employees in health-related fields, this certificate confirms that an individual is free from communicable diseases, much like the health verification needed for child care employees.
  • Occupational Health Questionnaire: This document gathers information about an employee's health status and any potential risks associated with their job. It shares the goal of ensuring that employees are fit for their work environment, similar to the JFS 01296.

Each of these documents plays a vital role in maintaining health standards and ensuring the well-being of both employees and the children they care for.

Dos and Don'ts

When filling out the Ohio JFS 01296 form, consider the following important dos and don'ts:

  • Do ensure the form is completed within 12 months prior to the first day of employment.
  • Do provide accurate personal information, including the employee's name and home address.
  • Do have a licensed health care provider complete the examination and sign the form.
  • Do verify that the employee is immunized against required diseases, including Tdap and MMR.
  • Don't submit the form without a signature from the health care provider.
  • Don't forget to include the date of examination on the form.
  • Don't use outdated immunization records; ensure all vaccinations are current.
  • Don't leave any sections of the form blank; fill in all required fields completely.

Misconceptions

Understanding the Ohio JFS 01296 form can be challenging, and several misconceptions often arise. Here are five common misunderstandings about this important document:

  • Misconception 1: The form is optional for employment.
  • Many people believe that the Ohio JFS 01296 form is optional for those seeking employment in child care facilities. In reality, it is a requirement set by the Ohio Administrative Code for licensing purposes.

  • Misconception 2: The physical examination can be done at any time.
  • Some assume that the physical examination can occur at any point before starting work. However, the examination must be completed no more than 12 months prior to the first day of employment to ensure that the information is current.

  • Misconception 3: Only physicians can complete the form.
  • There is a belief that only licensed physicians can sign off on the JFS 01296 form. In fact, it can also be signed by a physician's assistant, advanced practice nurse, or a certified nurse practitioner.

  • Misconception 4: Immunization records are not necessary.
  • Some people think that providing proof of immunizations is not necessary for employment. This is incorrect; verification of immunizations against specific diseases is a crucial part of the form and is required for all employees.

  • Misconception 5: The form does not have a deadline for submission.
  • Lastly, many individuals believe that there is no deadline for submitting the JFS 01296 form. However, it must be completed and submitted before the employee's first day of work to comply with licensing regulations.

Key takeaways

When dealing with the Ohio JFS 01296 form, it's important to understand its purpose and requirements. Here are key takeaways to keep in mind:

  • The form is officially titled "Employee Medical Statement for Child Care Centers and Type A Homes."
  • Completion of this form is mandated by specific Ohio Administrative Code rules.
  • It must be filled out no more than 12 months before the employee's first day of work.
  • Employees must be physically fit for employment in a child care facility.
  • Verification of immunization against Diphtheria/Tetanus/Pertussis (Tdap) is required.
  • Employees must also be immunized against Measles, Mumps, and Rubella (MMR).
  • For individuals born on or before December 31, 1956, a history of disease may substitute for some vaccinations.
  • A licensed physician, physician's assistant, advance practice nurse, or certified nurse practitioner can sign the form.
  • Ensure that the health care provider's information is clearly printed on the form.
  • Keep a copy of the completed form for your records, as it may be requested by licensing authorities.

Filling out the JFS 01296 form accurately and completely is crucial for compliance and the well-being of children in care. Make sure to follow all guidelines closely.