CCMTL 75 (Ch. 12 and Ch. 13 Forms, eff. 9/30/06)
Child Care Manual Transmittal Letter No. 75
August 7, 2006
TO: All Child Care Manual Holders
FROM: Barbara Riley, Director
SUBJECT: Forms for Licensed Child Care Centers and Type A Homes

This letter transmits revised forms to be used by child care centers and type A homes. These forms, some that are required and some that are samples, are intended to assist providers in meeting the requirements of rules in Chapters 5101:2-12 and 5101:2-13 of the Administrative Code. Effective September 30, 2006 the prescribed forms that are contained in this letter are the only ones that should be used in child care centers and type A homes. Prior to September 30, 2006 the center/home administrator may choose to use the old form or the new version.

There are two separate packets of forms. One packet contains prescribed forms. Prescribed forms must be used by providers in centers and type A homes to meet the standards of a rule. The format and content of the information cannot be changed and the form must be used in its entirety. The second packet contains sample forms, which have been designed to meet rule requirements. These forms may be used as they are or may be used as templates to set up forms with headings or logos particular to a center or type A home, however, changes to these forms should be limited as the content of the sample forms meets the requirements of the rules.

All of these forms will be available online in a PDF format. They may be downloaded and many of them will be able to be completed electronically. The forms may also be printed, copied and completed by hand. All previous versions of these forms are obsolete and should be removed from the manual.

The following is a list of the form numbers and titles included with this letter. The first list is the prescribed forms that have been revised with a description of the revisions. The second list is the sample forms.

Prescribed Forms

JFS 01201"Dental First Aid Chart" has been reformatted to fit on letter-size paper.

JFS 01209"Type A Home Information Letter" has been reformatted.

JFS 01210"Application for Child Care License" has been reformatted and has been revised to include civil rights information and additional information regarding past experience as a certified type B child care provider.

JFS 01234"Child Enrollment and Health Information" has been reformatted to allow more space for information.

JFS 01235*"Sleep Position Waiver Statement" has been reformatted.

JFS 01237"Center Parent Information" has been reformatted.

JFS 01240"Food Service License Exemption Report" has been reformatted.

JFS 01246*"Child Care Staff Member Employee Policy Review" has been reformatted.

JFS 01250"Plan of Operation for a Child Care Center" has been reformatted.

JFS 01257"License Renewal Notice" has been reformatted.

JFS 01258"Application for Child Day Camp Registration" has been reformatted and a civil rights statement added.

JFS 01299"Incident/Injury Report" has been reformatted.

JFS 01303"Fire Inspection Report" has been reformatted.

JFS 01307"Inservice Training" has been reformatted and language regarding first aid training has been amended.

JFS 01311"Request for a Criminal Records Check for an Initial License" has been reformatted and updated to include the current mailing address to which the form must be sent.

JFS 01313*"Statement of Nonconviction" has been reformatted and includes new offenses as required by the statutory changes following the passage of HB 11. Additionally, the new electronic webcheck process is referenced.

JFS 01314*"Owners & Administrators Statement of Nonconviction" has been reformatted and now provides an space for signature.

JFS 01335"Type A Home Initial Questionnaire" has been reformatted.

JFS 01336"Type A Home Building Inspection" has been reformatted.

JFS 01337"Type A Home Parent and Employee Information" has been reformatted.

Sample Forms

JFS 01207"Cleaning Requirements for Child Care Centers" is a new form providing information about current cleaning standards.

JFS 01208"Weekly Attendance" is a new form to assist with meeting the attendance requirements.

JFS 01212"Compliance Tips & Reminders" is a new form providing information to maintain compliance with licensing rules.

JFS 01213"Guidelines for Transportation/Fieldtrip Safety" is a new form that provides a chart explaining the transportation requirements.

JFS 01215"Children's Record Review" has been reformatted to allow more space for comments and information.

JFS 01216"Guidelines for Administration of Medication" is a new form that provides a chart explaining the medication requirements.

JFS 01218"Basic Infant Information" is a sample form that can be used to obtain basic information about an infant.

JFS 01219"Child Care Staff Member and Employee Requirements for Rule 25" is a chart that explains the requirements of rule 5101:2-12-25 for the different roles that are filled at a child care center.

JFS 01220"Suggested Play Equipment and Materials" has been updated to include additional materials and is now divided by age group.

JFS 01223"Monthly Attendance" is a sample form to assist n maintaining the attendance requirements.

JFS 01225"Routine Trip Permission" has been reformatted.

JFS 01226"Field Trip Permission" has been reformatted.

JFS 01227"Permission to Participate in Swimming Activities" has been reformatted.

JFS 01228"Infant Daily Report" has been reformatted.

JFS 01229"Transition Letter" has been reformatted.

JFS 01230*"Vehicle Inspection Report" has been reformatted

JFS 01232"Field Trip Checklist" has been reformatted.

JFS 01236"Child Medical/Physical Care Plan" has been reformatted and now provides a place for staff to indicate they have been informed of the condition as well as trained.

JFS 01238"Second Adult Statement" has been reformatted.

JFS 01242"Medical, Dental and General Emergency Plan" has been revised to add information that reduces the amount of directions that are needed.

JFS 01244"First Aid Supplies" has been revised to specify that thermometers used in child care centers and type A homes must be digital thermometers, as required in rule 5101:2-12-33. Additionally, it clarifies the type of cold pack to be included in the first aid kit and where supplies must be located.

JFS 01245"Verification of Five Years Ohio Residency" has been reformatted.

JFS 01248"License Capacity Determination" has been reformatted.

JFS 01250"Plan of Operation for a Child Care Center" has been reformatted.

JFS 01251"Inspection Guide: Type A Homes Meal Preparation and Water Sanitation" is a new form to assist type A providers in maintaining compliance with rule 5101:2-13-12.

JFS 01252"Types of Child Care Settings" is a new form that describes the different types of child care settings.

JFS 01253"Tips for Responding to an Inspection Report" is a new form that assists centers and homes in completing their response to a licensing inspection.

JFS 01260"Diaper Changing Instructions" is a new form that describes the individual steps needed to change a diaper in compliance with licensing rules.

JFS 01263"Guidelines for Primary Caregiving" is a new form that provides information about the practice of assigning primary caregivers.

JFS 01267"Transportation/Fieldtrip/Ratio/Second Adult Requirements" is a new chart that provides centers and homes with the requirements to be followed when transporting children.

JFS 01268*"Sample Parent Handbook" is a new form that child care centers may use to develop a complete parent policy handbook.

JFS 01269*"Handwashing Procedures" is a new form that describes the individual steps needed to wash hands in compliance with child care licensing rules.

JFS 01279"Handbook on Common Childhood Illnesses for Child Care Centers 2006" has been revised and updated by the Department of Health.

JFS 01296*"Employee Medical Statement" has been reformatted and language regarding recommended immunizations has been changed.

JFS 01298"Annual Fire Inspection Notice" has been reformatted.

JFS 01300"Child Care Employee Reference" has been reformatted.

JFS 01304"Child Care Owner Reference" has been reformatted.

JFS 01305*"Child Medical Statement" has been reformatted. Additional space is now available for physicians to record screenings that have been completed and language regarding immunizations has been amended.

JFS 01310"Required Staff/Child Ratios" is a new form presenting the required ratios and maximum group size to be followed for each age group of children.

The training manual, JFS 01273 "Handbook on Common Childhood Illnesses for Child Care Centers 2006", has also been updated and revised. This manual will not be available to be downloaded, it is available only to those persons who have attended the "Training of Trainers" for communicable disease training. More information can be obtained on the Child Care in Ohio website at:

Forms marked with an (*) will be revised again in the near future when additional rule changes have been finalized. It is recommended that these forms not be printed in large quantities at this time. Centers and type A home administrators will be notified when the next form and rule revisions are completed and the effective date of the changes. These changes are anticipated to be made in early 2007.

The electronic version of the Child Care Manual, located at:, contains all rules, forms, transmittal letters and procedure letters from the department to child care providers. This manual should be utilized by staff in all child care centers and type A homes that are licensed by the Department of Job and Family Services. A current and updated copy of the manual should be accessible at all times in the center or type A home.

Forms can be located by clicking on "Child Care Manual" on the left hand side of the page and then "Child Care Manual Appendix." ODJFS will notify all licensed centers and type A homes whenever forms are changed and the date of the change. When forms are obsolete they should no longer be used. The old version of the form should be removed and replaced with the new one. This will assure that the forms used are compliant with ODJFS child care licensing and type A family home rules.

Please contact the Bureau of Child Care and Development, Monitoring and Technical Assistance Section at (614) 466-3822, if you have any questions.

INSTRUCTIONS: The following chart identifies the material that needs to be removed from and inserted into the Child Care Manual (CCM).

Child Care Manual AppendixJFS 01201 (rev. 3/2004)JFS 01201 (rev. 9/2006)
Child Care Manual Appendix JFS 01207 (9/2006)
Child Care Manual Appendix JFS 01208 (9/2006)
Child Care Manual AppendixJFS 01209 (rev. 1/2006)JFS 01209 (rev. 9/2006)
Child Care Manual AppendixJFS 01210 (rev. 11/2004)JFS 01210 (rev. 9/2006)
Child Care Manual Appendix JFS 01212 (9/2006)
Child Care Manual Appendix JFS 01213 (9/2006)
Child Care Manual AppendixJFS 01215 (rev. 9/2003)JFS 01215 (rev. 9/2006)
Child Care Manual Appendix JFS 01216 (9/2006)
Child Care Manual Appendix JFS 01218 (9/2006)
Child Care Manual Appendix JFS 01219 (9/2006)
Child Care Manual AppendixJFS 01220 (rev. 9/1986)JFS 01220 (rev. 9/2006)
Child Care Manual Appendix JFS 01223 (9/2006)
Child Care Manual AppendixJFS 01225 (rev. 6/2004)JFS 01225 (9/2006)
Child Care Manual AppendixJFS 01226 (rev. 10/2004)JFS 01226 (9/2006)
Child Care Manual AppendixJFS 01227 (rev. 10/2004)JFS 01227 (9/2006)
Child Care Manual AppendixJFS 01228 (rev. 10/2004)JFS 01228 (9/2006)
Child Care Manual Appendix JFS 01229 (9/2006)
Child Care Manual AppendixJFS 01230 (rev. 6/2004)JFS 01230 (9/2006)
Child Care Manual AppendixJFS 01232 (rev. 6/2004)JFS 01232 (9/2006)
Child Care Manual AppendixJFS 01234 (rev. 7/2003)JFS 01234 (rev. 9/2006)
Child Care Manual AppendixJFS 01235 (rev. 4/2003)JFS 01235 (rev. 9/2006)
Child Care Manual AppendixJFS 01236 (rev. 4/2003)JFS 01236 (rev. 9/2006)
Child Care Manual AppendixJFS 01237 (rev. 4/2003)JFS 01237 (rev. 9/2006)
Child Care Manual AppendixJFS 01238 (rev. 4/2003)JFS 01238 (rev. 9/2006)
Child Care Manual AppendixJFS 01240 (rev. 4/2003)JFS 01240 (rev. 9/2006)
Child Care Manual AppendixJFS 01242 (rev. 7/2003)JFS 01242 (rev. 9/2006)
Child Care Manual AppendixJFS 01244 (rev. 3/2004)JFS 01244 (rev. 9/2006)
Child Care Manual Appendix JFS 01245 (9/2006)
Child Care Manual AppendixJFS 01246 (rev. 6/2004)JFS 01246 (rev. 9/2006)
Child Care Manual AppendixJFS 01248 (rev. 5/2004)JFS 01248 (rev. 9/2006)
Child Care Manual AppendixJFS 01250 (rev. 4/2003)JFS 01250 (rev. 9/2006)
Child Care Manual Appendix JFS 01251 (9/2006)
Child Care Manual Appendix JFS 01252 (9/2006)
Child Care Manual Appendix JFS 01253 (9/2006)
Child Care Manual AppendixJFS 01257 (rev. 10/2002)JFS 01257 (rev. 9/2006)
Child Care Manual AppendixJFS 01258 (rev. 11/2004)JFS 01258 (rev. 9/2006)
Child Care Manual Appendix JFS 01260 (9/2006)
Child Care Manual Appendix JFS 01263 (9/2006)
Child Care Manual Appendix JFS 01267 (9/2006)
Child Care Manual Appendix JFS 01268 (6/2005)
Child Care Manual Appendix JFS 01269 (9/2006)
Child Care Manual AppendixJFS 01279 (rev. 12/2002)JFS 01279 (4/2006)
Child Care Manual AppendixJFS 01296 (rev. 4/2003)JFS 01296 (rev. 9/2006)
Child Care Manual AppendixJFS 01298 (rev. 1/2003)JFS 01298 (rev. 9/2006)
Child Care Manual AppendixJFS 01299 (rev. 6/2004)JFS 01299 (rev. 9/2006)
Child Care Manual AppendixJFS 01300 (rev. 3/2004)JFS 01300 (rev. 9/2006)
Child Care Manual AppendixJFS 01303 (rev. 7/2003)JFS 01303 (rev. 9/2006)
Child Care Manual AppendixJFS 01304 (rev. 3/2002)JFS 01304 (rev. 9/2006)
Child Care Manual AppendixJFS 01305 (rev. 7/2003)JFS 01305 (rev. 9/2006)
Child Care Manual AppendixJFS 01307 (rev. 4/2003)JFS 01307 (rev. 6/2006)
Child Care Manual Appendix JFS 01310 (9/2006)
Child Care Manual AppendixJFS 01311 (rev. 10/1993)JFS 01311 (rev. 9/2006)
Child Care Manual AppendixJFS 01313 (rev. 7/2003)JFS 01313 (rev. 9/2006)
Child Care Manual AppendixJFS 01314 (rev. 8/2005)JFS 01314 (rev. 9/2006)
Child Care Manual AppendixJFS 01335 (rev. 4/2003JFS 01335 (rev. 9/2006)
Child Care Manual AppendixJFS 01336 (rev. 4/2003)JFS 01336 (rev. 6/2006)
Child Care Manual AppendixJFS 01337 (rev. 4/2003)JFS 01337 (rev. 9/2006)