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The Florida Certification of Immunization, commonly referred to as the 680 form, serves a crucial role in ensuring that children meet the immunization requirements necessary for school attendance. This form, backed by specific legal authorities including sections of the Florida Statutes, outlines the necessary vaccinations that children must receive before enrolling in K-12 education, daycare, or preschool. Parents or guardians must provide essential information such as the child's name, date of birth, and optional social security number. The form requires detailed documentation of each vaccine administered, including dates for multiple doses of vaccines like DTaP, MMR, and Hepatitis B. Additionally, it includes sections for certifying complete immunization, temporary medical exemptions, and permanent medical exemptions, each with its own set of guidelines. To assist in the completion of the form, reference materials like the Immunization Guidelines for Florida Schools are available online. Understanding the 680 form is vital for parents, guardians, and healthcare providers alike, as it ensures that children are protected against preventable diseases while facilitating their educational journey.

Dos and Don'ts

When filling out the Florida Certification of Immunization (Form 680), attention to detail is crucial. Here are some essential dos and don’ts to ensure a smooth process.

  • Do enter the child’s full name, including last name, first name, and middle initial accurately.
  • Do provide the date of birth in the correct format (MM/DD/YY).
  • Do list all appropriate vaccine doses and dates clearly in the designated sections.
  • Do sign and date the appropriate certificate (A, B, or C) at the end of the form.
  • Don't forget to check for any optional fields, such as the child’s Social Security number or State Immunization ID number.
  • Don't leave any required fields blank; incomplete forms may lead to delays.
  • Don't use white-out or any correction fluid on the form; it may render the document invalid.
  • Don't submit the form without reviewing it for accuracy and completeness first.

Document Attributes

Fact Name Description
Legal Authority The form is governed by Sections 1003.22, 402.305, 402.313 of the Florida Statutes and Rule 64D-3.046 of the Florida Administrative Code.
Purpose This form certifies a child's immunization status for school attendance in Florida.
Optional Information The child's Social Security Number and State Immunization ID Number are optional fields on the form.
Immunization Record Parents or guardians must enter all appropriate doses and dates of immunizations received by the child.
Exemptions The form provides options for temporary and permanent medical exemptions from immunizations.
Completion Guidelines For detailed instructions on completing the form, refer to DH Form 150-615 and the guidelines available at www.immunizeflorida.org/schoolguide.pdf.

Key takeaways

Here are key takeaways regarding the completion and use of the Florida Certification of Immunization Form 680:

  • Purpose: The form is used to document a child's immunization status for school attendance in Florida.
  • Information Required: The form requires the child's full name, date of birth, and optional information like Social Security number and state immunization ID.
  • Vaccine Documentation: All vaccine doses and their respective dates must be accurately entered in the designated sections.
  • Certificates: The form includes three parts: Part A for complete immunizations, Part B for temporary exemptions, and Part C for permanent exemptions.
  • Signature Requirement: A parent or guardian must sign the form to certify the information provided is accurate.
  • Expiration Dates: Temporary medical exemptions must include an expiration date to remain valid.
  • Guidelines: Refer to the Immunization Guidelines for Florida Schools for detailed instructions on completing the form.
  • Accessing Guidelines: Additional information can be found at www.immunizeflorida.org/schoolguide.pdf.
  • Submission: The completed form must be submitted to the appropriate school or childcare facility.
  • Record Keeping: Keep a copy of the completed form for personal records and future reference.

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

Detailed Instructions for Writing 680

Completing the Florida Certification of Immunization Form 680 requires careful attention to detail. This form is essential for ensuring that a child's immunization records are accurately documented for school attendance. Follow the steps below to fill out the form correctly.

  1. Begin by entering the child's last name, first name, and middle initial in the designated fields.
  2. Input the child's date of birth in the format MM/DD/YY.
  3. Provide the name of the parent or guardian.
  4. Fill in the child's Social Security Number (optional) and State Immunization ID Number (optional).
  5. Proceed to the section for vaccines. For each vaccine listed, enter the dose number and the corresponding date for doses 1 through 5.
  6. For vaccines like DTaP, Polio, MMR, and others, ensure you select the appropriate code next to each vaccine.
  7. Choose the correct certificate type by marking the appropriate box for Part A, Part B, or Part C based on the child's immunization status.
  8. If applicable, fill out the expiration date for a temporary medical exemption in Part B.
  9. For a permanent medical exemption in Part C, list each vaccine and provide valid clinical reasoning or evidence for the exemption.
  10. Sign and date the form in the designated areas for the physician or clinic representative.
  11. Ensure that the issued by section is filled out with the appropriate details.

After completing the form, review it carefully to ensure all information is accurate. This will help avoid any issues when submitting the form for school enrollment. Keep a copy for your records, as it may be needed for future reference.

Documents used along the form

The Florida Certification of Immunization, commonly referred to as the 680 form, is an essential document for students enrolling in schools and childcare facilities. Alongside this form, several other documents may be required to ensure compliance with immunization laws and regulations. Below is a list of related forms and documents that are often used in conjunction with the 680 form.

  • DH Form 150-615: This document provides detailed immunization guidelines for Florida schools, childcare facilities, and family daycare homes. It outlines the requirements for immunizations and instructions for completing the 680 form.
  • Health Examination Form: This form documents a child’s health status and is often required for school entry. It includes information on physical exams and any health concerns that may affect a child’s schooling.
  • Proof of Residency: Schools typically require proof of residency to verify that a child lives within the district. This may include utility bills, lease agreements, or other official documents showing the family’s address.
  • Birth Certificate: A certified copy of a child’s birth certificate is often needed to establish the child’s age and identity for school enrollment.
  • Emergency Contact Form: This document provides critical information about who to contact in case of an emergency. It includes names, phone numbers, and relationships of emergency contacts.
  • Durable Power of Attorney: This legal document enables a trusted individual to manage your financial affairs if you become incapacitated. For more details, you can refer to this helpful resource: https://newyorkform.com/free-durable-power-of-attorney-template/.
  • Medication Authorization Form: If a child requires medication during school hours, this form must be completed by a parent or guardian and signed by a physician. It outlines the medication, dosage, and administration schedule.
  • Special Education Assessment: For children requiring special education services, this assessment form documents the child’s educational needs and the services they will receive.
  • Transfer Records: If a child is transferring from another school, records from the previous institution may be necessary. These records typically include academic performance, attendance, and immunization history.

Each of these documents plays a vital role in ensuring that children meet the necessary requirements for school attendance and that their health and safety are prioritized. Properly completing and submitting these forms can help facilitate a smooth transition into educational settings.