Form JFS01643 "Application for Licensed Type B Home" - Ohio

What Is Form JFS01643?

This is a legal form that was released by the Ohio Department of Job and Family Services - a government authority operating within Ohio. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2014;
  • The latest edition provided by the Ohio Department of Job and Family Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form JFS01643 by clicking the link below or browse more documents and templates provided by the Ohio Department of Job and Family Services.

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Download Form JFS01643 "Application for Licensed Type B Home" - Ohio

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Ohio Department of Job and Family Services
APPLICATION FOR LICENSED TYPE B HOME
Section I - To Be Completed by County Department of Job and Family Services (CDJFS)
Home Telephone Number
Mobile Telephone Number
Submit this Application to (CDJFS name and address):
Name of CDJFS staff
Status of Application:
Date Application Submitted
Date Provider Agreement
Date BCII/FBI Checks Submitted
Completed
Date BCII Results Received
Date FBI Results Received
Date PCSA Request Submitted
Date PCSA Results Received
Date Initial Inspection Completed
Date Certificate Issued
Date Application Denied
Date License Recommended
Date License Issued
The information in Section II through Section V will give us an idea of the types of services you may be able to provide.
However, your answers to these questions will not be taken as a final commitment. The CDJFS staff will discuss this
information with you.
Section II - General Information
Name of Applicant
Birth Date
Social Security Number
E-Mail Address (required)
Address
Previous Last Names of Applicant
Telephone Number
City, State, and Zip Code
What is your educational level?
High School Graduate
Date
Which children are you willing to care for?
GED Diploma
Date
Infants (0-18 months)
Degree
College Graduate
Date
Toddlers (18-36 months)
Preschool children
How many of your own children are under the age of six?
Name:
Age:
School children
Children with special needs
When do you prefer to care for children?
Weekdays
Weekends
How many children other than your own are you caring for at this time?
Overnight
List their names and ages:
Are you presently employed inside or outside your own home?
Yes
No
If yes, complete the
chart below.
Name of Employer
City
Address
State
Zip Code
JFS 01643 (Rev. 1/2014)
Page 1 of 4
Ohio Department of Job and Family Services
APPLICATION FOR LICENSED TYPE B HOME
Section I - To Be Completed by County Department of Job and Family Services (CDJFS)
Home Telephone Number
Mobile Telephone Number
Submit this Application to (CDJFS name and address):
Name of CDJFS staff
Status of Application:
Date Application Submitted
Date Provider Agreement
Date BCII/FBI Checks Submitted
Completed
Date BCII Results Received
Date FBI Results Received
Date PCSA Request Submitted
Date PCSA Results Received
Date Initial Inspection Completed
Date Certificate Issued
Date Application Denied
Date License Recommended
Date License Issued
The information in Section II through Section V will give us an idea of the types of services you may be able to provide.
However, your answers to these questions will not be taken as a final commitment. The CDJFS staff will discuss this
information with you.
Section II - General Information
Name of Applicant
Birth Date
Social Security Number
E-Mail Address (required)
Address
Previous Last Names of Applicant
Telephone Number
City, State, and Zip Code
What is your educational level?
High School Graduate
Date
Which children are you willing to care for?
GED Diploma
Date
Infants (0-18 months)
Degree
College Graduate
Date
Toddlers (18-36 months)
Preschool children
How many of your own children are under the age of six?
Name:
Age:
School children
Children with special needs
When do you prefer to care for children?
Weekdays
Weekends
How many children other than your own are you caring for at this time?
Overnight
List their names and ages:
Are you presently employed inside or outside your own home?
Yes
No
If yes, complete the
chart below.
Name of Employer
City
Address
State
Zip Code
JFS 01643 (Rev. 1/2014)
Page 1 of 4
Hours Worked
Position
Day Working
Time of Work
Per Day
S
M
T
W
Th
F
Sat
S
M
T
W
Th
F
Sat
S
M
T
W
Th
F
Sat
S
M
T
W
Th
F
Sat
Are you currently receiving OWF benefits?
Are you a foster parent?
Yes
No
Yes
No
Are you a specialized care foster home?
Yes
No
Are you caring for foster children at this time?
If yes, please list their name and age
Yes
No
Name of foster care worker(s) and agency(ies)
Have you previously been certified or licensed or are you currently certified or licensed as a child care provider by the Ohio
Department of Job and Family Services (ODJFS) or any CDJFS?
Yes
No
If yes, please list
Do you have a swimming pool or open body of water 18 inches or deeper at your residence? If yes, it shall be inaccessible to
children.
Yes
No
Section III - Training and Experience
Have you had any formal training in child care?
Yes
No
If yes, complete this chart
Certificate, Diploma or
Year Completed
Name of Course
Credential Received
Summarize your previous experience in caring for children and/or in child care related employment and indicate the length of the
experience.
JFS 01643 (Rev. 1/2014)
Page 2 of 4
Section IV - List the people living in your home, including children, foster children, relatives and
boarders
First and Last Name
Social Security Number
Birth Date
Relationship to Applicant
Please show that you have or are willing to provide the following:
Evidence of physical examination as required by certification rule 5101:2-14-02
Yes
No
A working telephone
Yes
No
A complete first aid kit
Yes
No
A working smoke detector and carbon monoxide detector in the basement
and on each level
Yes
No
A stove or microwave and refrigerator in working order
Yes
No
Meals and snacks for the children receiving care
Yes
No
A separate crib or playpen for each infant receiving care
Yes
No
A bed, sofa, cot, pad or mat for each toddler. preschooler or school age child who rests
Yes
No
Evidence of laboratory approval of your water supply (for nonpublic water systems only)
Yes
No
DATE
An approved, portable fire extinguisher
Yes
No
Childproof protective covers for electrical outlets
Yes
No
A smoke-free environment
Yes
No
Information necessary to perform a BCII and an FBI criminal records check on you, other
adult residents in your home, emergency/substitute caregivers and employees
Yes
No
Information necessary for the PCSA to conduct an abuse and neglect registry search on
you and other adult residents in your home
Yes
No
JFS 01643 (Rev. 1/2014)
Page 3 of 4
Section VI - Signature
I am physically, intellectually and emotionally capable of complying with Chapter 5101:2-14 of the Ohio
Administrative Code and can perform all activities related to child care.
I agree to complete the required documents by logging onto the ODJFS Provider Portal at:
http://jfs.ohio.gov/cdc/childcare.stm
I understand that the submission of these documents through the Provider Portal must be completed
before I provide any publicly funded child care services and that these forms are necessary in order for
ODJFS to reimburse me for providing publicly funded child care services in my home.
I understand that approval of this application is based on the information I have provided and information
obtained during a home inspection. Any false or misleading statements made on this application may be
grounds for denial of my application or revocation of my license. To the best of my knowledge the
information I have given is true and correct.
My signature below means that I have read and agree to the terms of this application.
Signature of Applicant
Date
This form is used to meet the requirements of chapter 5101:2-14 of the Administrative Code.
JFS 01643 (Rev. 1/2014)
Page 4 of 4
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