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Fill Out a Valid 680 Form

The 680 form, officially known as the Florida Certification of Immunization, is a document required for school attendance in Florida. It verifies that a child has received the necessary immunizations as mandated by state law. Parents or guardians must complete this form accurately to ensure compliance with health regulations.

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Table of Contents

Form Overview

Fact Name Description
Legal Authority The form is governed by Sections 1003.22, 402.305, and 402.313 of the Florida Statutes, along with Rule 64D-3.046 of the Florida Administrative Code.
Purpose This form serves as a Certification of Immunization for children attending Florida schools, daycare facilities, and family daycare homes.
Immunization Records Parents or guardians must enter all appropriate vaccine doses and corresponding dates in the designated sections of the form.
Exemption Options The form provides options for temporary and permanent medical exemptions, allowing for documentation of valid clinical reasoning.
Completion Guidelines Detailed guidelines for completing the form can be found in DH Form 150-615, which is accessible online at www.immunizeflorida.org/schoolguide.pdf.
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Documents used along the form

The Florida Certification of Immunization, commonly known as the DH Form 680, is an important document for students entering school or childcare. Along with this form, there are several other documents that may be required or helpful in the process of ensuring a child's immunization records are complete. Below is a list of these forms and documents.

  • DH Form 150-615: This form provides immunization guidelines for Florida schools, childcare facilities, and family daycare homes. It offers detailed instructions on how to complete the DH Form 680 correctly.
  • Temporary Medical Exemption Form: This document is used when a child cannot receive certain immunizations due to temporary medical reasons. It must include an expiration date to be valid.
  • Permanent Medical Exemption Form: This form is for children who cannot receive specific vaccines due to permanent medical conditions. It requires a physician’s signature and must clearly state the medical reasoning for the exemption.
  • School Admission Forms: Many schools have their own admission forms that may require proof of immunizations. These forms often ask for the DH Form 680 or similar documentation.
  • Health Records: Parents may need to provide additional health records that document a child's medical history, including previous illnesses or vaccinations that could impact immunization requirements.
  • Immunization Records from Healthcare Providers: These records from doctors or clinics detail the immunizations a child has received. They can serve as proof when submitting the DH Form 680.

Having these documents ready can help streamline the process of enrolling a child in school or childcare. It’s always a good idea to check with the specific institution for any additional requirements they may have.

Document 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