(A) If a child care provider accurately answers the questions on a child care disclosure form that is in substantially the form set forth in division (B) of this section, presents the form to a person identified in division (A)(1) or (2) of section 2919.224 of the Revised Code, and obtains the person’s signature on the acknowledgement in the form, to the extent that the information set forth on the form is accurate, the provider who presents the form is not subject to prosecution under division (A) of section 2919.224 of the Revised Code regarding presentation of that information to that person.

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An owner, provider, or administrator of a type A family child care home or a type B family child care home may comply with division (A) of section 2919.225 of the Revised Code by accurately answering the questions on a child care disclosure form that is in substantially the form set forth in division (B) of this section, providing a copy of the form to the parent, guardian, custodian, or other person responsible for the care of a child and to whom disclosure is to be made under division (A) of section 2919.225 of the Revised Code, and obtaining the person’s signature on the acknowledgement in the form.

The use of the form set forth in division (B) of this section is discretionary and is not required to comply with any disclosure requirement contained in section 2919.225 of the Revised Code or for any purpose related to section 2919.224 of the Revised Code.

(B) To be sufficient for the purposes described in division (A) of this section, a child care disclosure form shall be in substantially the following form:

“CHILD CARE DISCLOSURE FORM

Please Note: This form contains information that is accurate only at the time the form is given to you. The information provided in this form is likely to change over time. It is the duty of the person responsible for the care of the child to monitor the status of child care services to ensure that those services remain satisfactory. If a question on this form is left unanswered, the child care provider makes no assertion regarding the question. Choosing appropriate child care for a child is a serious responsibility, and the person responsible for the care of the child is encouraged to make all appropriate inquiries. Also, in acknowledging receipt of this form, the person responsible for the care of the child acknowledges that in selecting the child care provider the person is not relying on any representations other than those provided in this form unless the child care provider has acknowledged the other representations in writing.

1. What are the names and qualifications to provide child care of: (a) the child care provider, (b) the employee who will provide child care to the applicant child, (c) the volunteer who will provide child care to the applicant child, and (d) any other employees or volunteers of the child care provider? (attach additional sheets if necessary): ________________________________________________________________________________________________________________________________________________________________________________________________

2. What is the maximum number of children to whom you provide child care at one time? (If children are divided into groups or classes, please describe the maximum number of children in each group or class and indicate the group or class in which the applicant child will be placed.): ________________________________________________________________________________________________________________________________________________________________________________________________

3. Where in the home will you provide child care to the applicant child?: ________________________________________________________________________________________________________________________________________________________________________________________________

4. Has a child died while in the care of, or receiving child care from, the child care provider? (Yes/No)

Description/explanation (attach additional sheets if necessary) ________________________________________________________________________________________________________________________________________________________________________________________________

5. Has a child died as a result of injuries suffered while under the care of, or receiving child care from, the child care provider? (Yes/No)

Description/explanation (attach additional sheets if necessary) ________________________________________________________________________________________________________________________________________________________________________________________________

6. Within the preceding ten years, has a child suffered injuries while under the care of, or receiving child care from, the child care provider that led to the child being hospitalized for more than 24 hours? (Yes/No)

Description/explanation (attach additional sheets if necessary) ________________________________________________________________________________________________________________________________________________________________________________________________ ______________________________________ ___________ Signature of person completing form Date ________________________________ Name of person completing form (Typed or printed) ________________________________ Title of person completing form (Typed or printed)

Acknowledgement:

I hereby acknowledge that I have been given a copy of the preceding document and have read and understood its contents. I further acknowledge that I am not relying on any other representations in selecting the child care provider unless the child care provider has acknowledged the other representations in writing.

Person receiving the form Date”

(C) If a child care provider accurately answers the questions on a disclosure form that is substantially similar to the form described in division (B) of this section, presents the form to a person identified in division (A)(1) or (2) of section 2919.224 of the Revised Code, and obtains the person’s signature on the acknowledgement in the form, to the extent that the information set forth on the form is accurate, the form is sufficient for the purposes described in division (A) of this section.

An owner, provider, or administrator of a type A family child care home or a type B family child care home who accurately answers the questions on a disclosure form that is substantially similar to the form described in division (B) of this section, provides a copy of the completed form to the parent, guardian, custodian, or other person who is responsible for the care of a child and to whom disclosure is to be made under division (A) of section 2919.225 of the Revised Code, and obtains the person’s signature on the acknowledgement in the form complies with the requirements of that division. If the owner, provider, or administrator uses the disclosure form, leaving a portion of the disclosure form blank does not constitute a misrepresentation for the purposes of section 2919.224 of the Revised Code but may constitute a violation of section 2919.225 of the Revised Code. The owner, provider, or administrator of a type A family child care home or type B family child care home who completes the disclosure form and provides a copy of the form to any person described in section 2919.224 or 2919.225 of the Revised Code may retain a copy of the completed form.