Free 680 PDF Form Get Document

Free 680 PDF Form

The Florida Certification of Immunization, commonly known as the 680 form, is a crucial document that verifies a child's immunization status for school enrollment. This form is governed by specific Florida statutes and administrative rules, ensuring compliance with state health regulations. To ensure your child's educational journey begins smoothly, consider filling out the 680 form by clicking the button below.

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Outline

The Florida Certification of Immunization, commonly known as the 680 form, is an important document for parents and guardians of children attending school or daycare in Florida. This form serves to verify that a child has received the necessary immunizations as required by state law. It includes sections for the child’s personal information, such as their name, date of birth, and immunization history. Parents or guardians must enter the specific vaccines administered, along with the corresponding dates. The form also provides options for certifying complete immunization, indicating a temporary medical exemption, or stating a permanent medical exemption due to contraindications. Proper completion of the 680 form is essential for school enrollment and compliance with health regulations. For guidance on filling out the form, additional resources are available, including the Immunization Guidelines for Florida Schools. This ensures that families have the necessary information to navigate the immunization requirements effectively.

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Change of Duty Ncoer - The contact information for raters and reviewers must be registered on the form.

Key takeaways

Below are key takeaways regarding the completion and use of the 680 form for immunization certification in Florida:

  • The 680 form is used to certify a child's immunization status for school attendance in Florida.
  • Legal authority for the form is derived from various Florida Statutes and Administrative Codes.
  • Essential information required includes the child's full name, date of birth, and parent or guardian details.
  • Immunization records must be documented accurately, including specific vaccine doses and dates.
  • There are three parts to the form: Part A for complete immunizations, Part B for temporary exemptions, and Part C for permanent exemptions.
  • Part A is applicable for K-12 students, while Part B addresses children in daycare and preschool settings.
  • Temporary medical exemptions must include an expiration date to remain valid.
  • For permanent medical exemptions, a valid clinical reason must be provided for each vaccine listed.
  • The form must be signed and dated by an authorized physician or clinic representative.
  • Additional guidelines for completing the form can be found in the Immunization Guidelines document, available online.

Form Preview Example

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