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680 Sample

FLORIDA CERTIFICATION OF IMMUNIZATION

Legal Authority: Sections 1003.22, 402.305, 402.313, Florida Statutes; Rule 64D-3.046, Florida Administrative Code

 

 

 

 

 

 

 

 

 

 

LAST NAME

 

FIRST NAME

 

MI

 

DOB (MM/DD/YY)

 

 

 

 

 

 

 

 

 

 

PARENT OR GUARDIAN

 

CHILD’S SS# (optional)

 

STATE IMMUNIZATION ID# (optional)

 

 

 

 

 

 

 

 

 

 

Directions:

Enter all appropriate doses and dates below.

Sign and date appropriate certificate (A, B,or C) on form.

See DH Form 150-615, Immunization Guidelines - Florida Schools, Childcare Facilities and Family Daycare Homes (July 2010) for information and instructions on form completion. Guidelines are available at: www.immunizeflorida.org/schoolguide.pdf.

VACCINE

DOE

Dose 1

 

Dose 2

 

Dose 3

 

Dose 4

 

Dose 5

 

CODE

MM/DD/YY

 

MM/DD/YY

 

MM/DD/YY

 

MM/DD/YY

 

MM/DD/YY

DTaP/DTP

A

 

 

 

 

 

 

 

 

 

DT

B

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Tdap

P

 

 

 

 

 

 

 

 

 

Td

Q

 

 

 

 

 

 

 

 

 

Polio

D

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Hib

E

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MMR (Combined)

F

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Separate)

G, H

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Measles (dose 1)

 

Measles (dose 2)

 

Mumps (dose 1)

 

Mumps (dose 2)

 

 

 

I

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Rubella (dose 1)

 

Rubella (dose 2)

 

 

 

 

 

 

Hepatitis B

J

 

 

 

 

 

 

 

 

 

Varicella

K

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Varicella Disease

L

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Year

PneumoConju N

Select appropriatebox(es)

Certificate of Immunization forK-12

Part A-Complete

DOE Code 1: Immunizations are complete K-12 (Excluding 7th grade/middle school requirements)

DOE Code 8: Immunizationsare complete for 7th grade

I have reviewed the records available,and to the best of my knowledge, the above named child has adequately been immunized for school attendance, as documented above.

Temporary Medical Exemption

Expiration date: _____________

Part B-Temporary

 

Part B (For children in daycare, family daycare homes, preschool, kindergarten and grades 1 through 12 who are incomplete for immunizations in Part A) Invalid without expiration date. DOE Code 2

I certify that the above named child has received the immunizations documented above and has commenced a schedule to complete the required immunization. Additional immunizations are not medically indicated at this time.

Permanent Medical Exemption

Part C-Permanent

Part C (For medically contraindicated immunizations, list each vaccine and state valid clinical reasoning or evidence for exemption.) DOE Code 3 ________________________________________________________________________________________

I certify the physical condition of this child is such that immunizations as indicated in Part C above are medically contraindicated.

Physician or Clinic Name:

Physician or

_________________________________________________

Authorized Signature: ____________________________________

_________________________________________________

Issued By:_____________________________________________

_________________________________________________

Date: _________________________________________________

DH 680 (Jul 2010) Stock Number: 5740-000-0680-6

⇓ PDF File

Instructions on Utilizing 680

Completing the 680 form is an important step in ensuring that your child meets the immunization requirements for school. It is essential to provide accurate information and follow the guidelines carefully. Below are the steps to help you fill out the form correctly.

  1. Begin by entering your child's last name, first name, and middle initial in the designated fields.
  2. Fill in your child's date of birth in the format MM/DD/YY.
  3. Provide the name of the parent or guardian in the appropriate space.
  4. If applicable, include your child's Social Security number and state immunization ID number in the optional fields.
  5. In the section labeled VACCINE, list the vaccines your child has received.
  6. For each vaccine, enter the dates for each dose (Dose 1, Dose 2, etc.) in the format MM/DD/YY.
  7. After completing the vaccine information, select the appropriate box for the certificate of immunization (Part A, B, or C) based on your child's immunization status.
  8. If applicable, provide the expiration date for any temporary medical exemption.
  9. In the designated area for Part C, list any vaccines for which your child has a permanent medical exemption and provide the reasoning.
  10. Finally, have the physician or clinic name and authorized signature filled out, along with the date of issuance.

Misconceptions

Misconceptions about the Florida Certification of Immunization Form 680 can lead to confusion among parents and guardians. Here are ten common misunderstandings clarified:

  1. Form 680 is only for school-age children. This form is applicable for children in daycare, preschool, kindergarten, and grades 1 through 12, not just for K-12 students.
  2. Immunization records are not required for daycare. Daycare facilities often require proof of immunization, making this form essential for enrollment.
  3. All vaccines must be completed before submitting the form. The form allows for temporary exemptions if a child has not yet completed all required immunizations.
  4. Parents can fill out the form without medical input. A healthcare provider must sign the form to validate the immunization records and any exemptions.
  5. Only the child's name is needed on the form. The form also requires the parent or guardian's name, ensuring proper identification and accountability.
  6. The form can be submitted without a signature. A signature from an authorized healthcare provider is mandatory for the form to be considered valid.
  7. Expiration dates are not necessary for exemptions. Temporary medical exemptions must include an expiration date to be valid.
  8. All vaccines are required regardless of medical conditions. The form allows for permanent medical exemptions for children with contraindications to specific vaccines.
  9. Immunization records do not need to be detailed. The form requires specific doses and dates for each vaccine administered.
  10. There is no online resource for help with the form. Guidelines and additional information are available at www.immunizeflorida.org/schoolguide.pdf, providing valuable assistance.

Understanding these points can help ensure compliance with Florida's immunization requirements and facilitate a smoother enrollment process for children in educational and childcare settings.

Documents used along the form

The Florida Certification of Immunization, commonly referred to as the 680 form, is essential for ensuring that children meet the immunization requirements for school attendance. Alongside this form, several other documents are frequently utilized to provide comprehensive immunization records and support various medical exemptions. Below is a list of related forms and documents that may accompany the 680 form.

  • DH Form 150-615: This document provides detailed immunization guidelines specifically for Florida schools, childcare facilities, and family daycare homes. It includes instructions on completing the 680 form and outlines the immunization requirements for different age groups.
  • Washington Trailer Bill of Sale form: This document is essential for recording the sale of a trailer in Washington, protecting the interests of both the buyer and seller. For more information, visit All Washington Forms.
  • Temporary Medical Exemption Form: This form is used when a child cannot receive specific vaccinations due to a temporary medical condition. It must include an expiration date and is critical for allowing continued school attendance while the child’s immunization status is being resolved.
  • Permanent Medical Exemption Form: For children with long-term medical conditions that contraindicate immunizations, this form is necessary. It requires documentation from a physician detailing the medical reasons for the exemption and ensures that the child's health needs are recognized.
  • Immunization Records: These are official documents from healthcare providers that detail a child's vaccination history. They serve as proof of immunizations received and may be requested by schools to verify compliance with state requirements.
  • School Health Assessment Form: Often required by schools, this form assesses a child’s overall health and may include information on immunizations, physical exams, and any health concerns. It helps schools ensure that children are fit for participation in school activities.
  • Parental Consent Forms: These forms are necessary for parents or guardians to authorize the administration of vaccines to their children. They may also be required for sharing immunization records with schools or other entities.

In summary, the 680 form is part of a broader framework of documentation that supports the health and safety of children in educational settings. Understanding these related forms can help parents navigate the requirements for school attendance and ensure their children are adequately protected through immunization.