Get Ohio Rule 51012 12 25 Form

The Ohio Rule 51012 12 25 Form is a crucial document required for the employment of individuals in child care centers and type A homes. This guide will provide you with clear, step-by-step instructions to ensure you complete the form accurately and efficiently.

Follow the steps to complete the Ohio Rule 51012 12 25 Form online.

1. Click the ‘Get Form’ button to access the form and open it in your online editor.
2. Begin filling in the 'Name of Employee' field with the full name of the individual being examined.
3. Enter the 'Home Address' of the employee, ensuring that all components of the address are included.
4. Provide the 'First Day of Employment' date for the individual to ensure compliance with the timeline requirements.
5. Check the box corresponding to the employee's physical condition. Select 'Physically fit for employment in a facility caring for children' if applicable.
6. Indicate the employee's immunization status by checking the appropriate boxes for Diphtheria/Tetanus/Pertussis (Tdap) and Measles, Mumps, and Rubella (MMR).
7. If the employee was born on or before December 31, 1956, ensure to provide a history of mumps or measles disease where applicable.
8. Fill in the 'Name of Health Care Provider' field clearly and in print.
9. Provide the 'Street Address', 'City, State, Zip' of the health care provider who performed the examination.
10. The health care provider must sign the form in the 'Signature of Health Care Provider' field.
11. Include the 'Phone Number' and 'Date of Examination', ensuring accuracy for any necessary follow-up.
12. Once all fields are completed, save your changes, download a copy for your records, and/or print or share the completed form as needed.

Complete your documents online today to ensure compliance with Ohio Administrative Code requirements.