Fill in a Valid 680 Form Get Your 680 Now

Fill in a Valid 680 Form

The 680 form, officially known as the Florida Certification of Immunization, is a crucial document that verifies a child's immunization status for school attendance. It is governed by various sections of Florida Statutes and Administrative Code, ensuring compliance with state health regulations. Parents or guardians must complete this form to document the necessary vaccinations, providing essential information for their child's educational journey.

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Common PDF Templates

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Example - 680 Form

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

Documents used along the form

The FLORIDA CERTIFICATION OF IMMUNIZATION, commonly known as the 680 form, is essential for documenting a child's immunization status for school attendance. Several other forms and documents often accompany the 680 form to provide additional information or fulfill specific requirements. Below is a list of these documents.

  • DH Form 150-615: This form contains immunization guidelines for Florida schools, childcare facilities, and family daycare homes. It provides detailed instructions on how to complete the 680 form.
  • Certificate of Medical Exemption: This document certifies that a child is medically exempt from receiving certain vaccinations due to health reasons. It must be signed by a licensed physician.
  • Health History Form: This form collects information about a child's medical history, including previous illnesses and allergies, which may affect immunization decisions.
  • School Enrollment Form: Required by schools, this form gathers essential information about the student, including personal details, emergency contacts, and health information.
  • Emergency Contact Form: This document provides the school with contact information for individuals who can be reached in case of an emergency involving the child.
  • Physical Examination Form: A record of a child's recent physical exam, this form may be necessary for school enrollment and can include immunization records.
  • Consent for Treatment Form: This form grants permission for school personnel to seek medical treatment for a child in case of an emergency.
  • Divorce Settlement Agreement Form: To navigate the complexities of divorce, refer to our detailed Divorce Settlement Agreement guidelines for proper documentation of your settlement terms.
  • Student Health Services Form: Used by school health services, this document allows parents to provide information about their child's health needs and any required accommodations.
  • Special Education Evaluation Form: For children who may require special education services, this form documents the need for evaluation and services related to health and learning.
  • Transportation Permission Form: This form gives permission for a child to use school transportation services, including bus routes, and may require health information for safe travel.

These documents work together to ensure that a child's health and educational needs are met while complying with state regulations. Keeping these forms organized and accessible can help facilitate a smooth enrollment process in schools and childcare facilities.