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Section I - Medical Provider Information

Section I - Medical Provider Information 2026

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The document is an Employee Medical Statement form used by the Office of Early Learning and School Readiness in Ohio, which complies with Ohio Administrative Code. It requires medical provider information, employee medical status certification regarding communicable diseases, and details any medical limitations. The form must be completed by qualified medical professionals and updated regularly as per program policy. Itinerant teachers and related service personnel must provide documentation every three years.

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Click ‘Get Form’ to open it in the editor.
Begin by entering the Physician/Clinic/Hospital Name in the designated field. This identifies the medical provider responsible for the employee's health assessment.
Next, fill in the Provider Address. Ensure that you include all relevant details such as street address, city, state, and zip code to maintain accurate records.
Input the Provider Phone Number. This is crucial for any follow-up communication regarding the medical statement.

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