Ohio Department of Job and Family Services

Ohio Department of Job and Family Services CHILD ENROLMENT AND HEALTH INFORMATION FOR TYPE B FAMILY CHILD CARE AND IN-HOME AIDES

Child’s Name Date of Birth Date form completed / First Day in Care updated

Home Address City Names of additional children in the family in care:

State Zip Code Home Telephone Number

Parent / Guardian Name: Relationship to Child:

Home Address:

City: State: Zip:

Home Telephone Number: Cell Phone:

Employer / School / Training Work / School / Training Telephone Number

Address: City:

Pager and Directions for Use:

Where can you be reached while your child is in this program?

Parent / Guardian Name: Relationship to Child:

Home Address:

City: State: Zip:

Home Telephone Number: Cell Phone:

Employer / School / Training Work / School / Training Telephone Number

Address: City:

Pager and Directions for Use:

Where can you be reached while your child is in this program?

Emergency Contacts: List the names of two local persons who you want to be contacted in the event of an emergency or illness if the parent/guardian cannot be reached. Persons listed should be able to assist in locating the parent/ guardian and at least one person listed must be able to take responsibility for the child in cases where the parent/guardian can not be located. Parents cannot be listed as emergency contacts.

Name: Name:

City: State: City: State:

Telephone Number: Relationship to Child: Telephone Number: Relationship to Child:

Other numbers where emergency contact can be reached Other numbers where emergency contact can be reached (optional) (optional)

Name of Child’s Physician or Clinic / Hospital Name of Child’s Dentist or Clinic

Street Address: Street Address:

City: State: Telephone City: State: Telephone Number: Number:

Note: This is a prescribed form provided by JFS which must be used by Type B Homes and in-home aides to meet the requirements of chapter 5101:2-14. This form must be completed and on file at the Type B home or with the in-home aide on or before the child’s first day of attendance.

JFS 01297 (Rev. 8/2008) Page 1 of 2 Child’s Name: Complete Box 1 OR Box 2. Do NOT complete both Box 1. Give Permission to Transport Box 2. Do Not Give Permission to Transport I give (Carla’s Kids Daycare, in home aide or their I do not give (Carla’s Kids Daycare, in home aide or emergency caregiver) _____ OR their emergency caregiver) __ Permission to have my child (name) Do not sign both ______My permission to have my child ______Transported to (hospital / clinic) ______Transported for emergency medical or dental care. ______In the event of an illness or injury which requires For emergency medical care or to (dentist) emergency medical or dental treatment, I wish for ______the following action to be taken: ______for emergency ______Dental care, or to the nearest available source of ______assistance. Caretaker/Parent Signature Date:

Allergies (food, medication or environmental) and precautions, reactions and treatment. * Check here if not applicable

Medications, food supplements, modified diet currently being administered.

Chronic Physical Problems

History of Hospitalization

History of disease the child has had

Any additional health or enrollment information on you feel I should know about your child.

*Any health condition that may require the provider to take action or medical procedure that may need to be completed while the child is in the care, must be documented on a JFS 01928 “Medical/Health Care Plan.” Immunizations (enter month, day and year) (Not required for children enrolled in school) Vaccine Dose 1 Does 2 Does 3 Does 4 Dose 5 Diphtheria, Tetanus, Pertussis (DTaP) Hepatitis B (Hep B) Haemophilus Influenza type B (HIB) Measles, Mumps, Rubella (MMR) Inactivated Polio Varicella (chicken pox) Influenza Pneumococcal Conjugate (PCV) Other

Note: This is a prescribed form provided by JFS which must be used by Type B homes and in-home aides to meet the requirements of chapter 5101:2-14. This form must be completed and on file at the Type B home or with the in-home aide on or before the child’s first day of attendance.

Distribution for in-home aides. Original to county agency, copy to in-home aide, copy to parent/caraetaker. Distribution for Type B Homes: Original to provider, copy to county, copy to Parent/caretaker

JFS 01297 (Rev. 8/2008) Ohio Department of Job and Family Services CHILD MEDICAL / PHYSICAL CARE PLAN FOR TYPE B FAMILY CHILD CARE AND IN-HOME AIDES

Child’s Name: Date of Birth: Special Health Considerations:

Symptoms to watch for and emergency action to be taken if the following symptoms occur.

Activities / foods / environmental conditions to Avoid

Medical Procedures to be followed and Expected Benefit of Treatment:

Are any medications required? ___ No ___ Yes (If yes, complete JFS 01644 Request for Administration of Medication) If yes, What Medications? Training Instructions (Trainer must be a caretaker / parent or certified professional) Signature of Trainer: Date:

Signature of trained providers who have been made aware of the condition. (Thee must always be a trained provider present when the child is present.)

Signature: ______Date: ______Provider Informed _____ Provider Trained: _____

(Only trained providers or emergency or substitute caregivers shall be permitted to perform medical procedures listed above.) Additional services (educational / therapeutic) child is receiving Who provides the above services?

Name: ______Phone number ______May we contact __ No __Yes

Name: ______Phone number ______May we contact __ No __Yes I give my permission for the staff listed above to perform the procedures in my child’s Medical / Physical Care Plan. Caretaker / Parent Signature: Date:

Provider Signature: Date:

This form may be used for children with health conditions as defined in Rules 5101: 2-14-27

JFS01928 (Rev. 8/2008) Ohio Department of Job and Family Services SLEEP POSITON WAIVER STATEMENT FOR TYPE B HOMES AND IN-HOME AIDES

Safe Sleep Practices

Sudden Infant Death Syndrome (SIDS) is the sudden and unexplained death of an infant under one year of age. SIDS, sometimes known as crib death, strikes nearly 2500 babies in the United States every year. Doctors don’t know what causes SIDS, but they have found some things that can make babies safer. The American Academy of Pediatrics and the National Institute of Child Health and Human Development state that one of the most important things that can help reduc the rist of SIDS is to put health babies on their backs to sleep. A few babies have health or medical conditions that might rqurie them to sleep in an alternate position. State regulations, require Type B Family Home providers and In-Home Aide to place infants to sleep on their back. At the advice of the infant’s physician, the provider may be authorized to use an alternate sleep position for the infant due to health or medical conditions.

To Be Completed by the Infant’s Caretaker (Parent/Guardian) Name of Infant: Date of Birth: Name of Primary Care Physician:

Name of Practice:

Address:

Phone: Fax (Optional) Email (Optional)

Signature of Caretaker / Parent (authorizing this instruction) Date:

To Be Completed by the Infant’s Primary Physician The above named infant has the following health or medical condition that necessitates an alternative sleep position

Describe the appropriate sleep position for the above named infant

Additional instructions:

Signature of Physician: Date:

This above instruction is effective from (date) to (date)

This is a prescribed form provided by ODJFS that must be used by type B family child care providers and in-home aides to meet the requirements of rule 5101: 2-14-36

JFS 01930 (Rev. 8/2008) Ohio Department of Job and Family Services PERMISSION TO ADMINISTER MEDICATION FOR TYPE B FAMILY CHILD CARE ANDIN-HOME AIDES IMPORTANT: Complete a separate form for each child and each medication Directions: Please take the time to read and understand all directions. All areas must be completed accurately to assure that the proper child receives the proper medication at the proper time via the proper route. Step One- Determine if medication is: ___ “Over the counter (OTC)-complete Box 1 ___Food Supplement or Modified Diet-complete Box 1 and 2 ___ Prescription w/label attached-complete Box 1 ___ Topical product or lotion used as a preventative, up to one ___ Sample Meds- Complete Box 1 and 2 year-complete box 1 ___ OTC as prescribed by a health caregiver ___ Topical product or lotion used for treatment of a condition

-Complete Box 1, (valid for 14 days) Step Two- Hand medication (in the original container w/original label) to the provider assuring that the child’s name is clearly indicated on the medication container. Step Three- Provider/In-home aide reads the JFS 01644 and assures the caretaker has completed all required information and the provider understands the information. Assures caretaker has administered first dose of medication to child. Step Four- Provider/in-home aide places medication in a safe location out of the reach of children. Does medication require refrigeration? ___Yes ___No Step Five- Provider/in-home aide administers medication at proper time and records it on this form. Step Six- Medication is sent home with the caretaker when no longer being administered or when it is expired. ___ Box 1: Caretaker/Parent Request for Administration of Medication. Complete for all products to be Administered or applied to the child. Name of Child: Date of Birth: Weight: Name of Medication: Exact Dosage (may not be “as needed”) Route (Ex: by mouth, in the eye, in the ear, etc.) To be administered at the following To be administered for the following Expiration date of medication: times: period of time: Is this medication a result of a special need or medical/health condition which may require the provider to have a Medical/Health Care Plan on file? ___ Yes ___ No. I give permission to the provider to administer the above medication to my child. I assure that my child has received the first dose of this medication and has not had any unexpected reactions. This permission is valid for no more then twelve months from the date of signature. Caretaker/Parent Signature: Date of Signature:

Box 2: To be completed by the child’s physician, dentist, physician’s assistant or certified nurse practitioner for sample medications, OTC medication administered not in accordance with label instructions, for nonprescription medications that contain codeine or aspirin or for modified diets (when the entire food group is eliminated) or for food supplements. Name of Child: Medication/Supplement/Vitamin Dosage: Expiration Date (May not exceed 12 months) Instructions:

This child is under my care and should receive the above medication as written. Healthcare Provider’s Signature: Date: Telephone Number

Address: City:

JFS 01644 (Rev. 8/2008) Page 1 of 2 Medication Log (Record all medications/products when administered ) Date Amount Time Provider’s Signature

This is a prescribed form which must be used to meet the requirement of Chapter 5101:2-14 of the Administrate Code

JFS 01644 (Rev. 8/2008)