Free 680 PDF Form

Free 680 PDF Form

The 680 form, also known as the Florida Certification of Immunization, is a crucial document that verifies a child's immunization status for school attendance. This form ensures that children meet the necessary vaccination requirements set forth by Florida law. Parents or guardians must complete the form accurately to facilitate their child's enrollment in educational settings.

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The Florida Certification of Immunization, commonly referred to as the 680 form, plays a crucial role in ensuring that children meet the immunization requirements for school attendance in the state of Florida. This form is governed by various legal authorities, including specific sections of the Florida Statutes and the Florida Administrative Code, which outline the requirements for immunization documentation. Parents or guardians are required to provide essential information such as the child’s name, date of birth, and optional identification numbers. The form allows for the entry of multiple vaccine doses, along with their corresponding dates, ensuring that children receive the necessary immunizations, including DTaP, MMR, and Hepatitis B, among others. It also includes sections for certifying complete immunization records, requesting temporary medical exemptions, or documenting permanent medical exemptions due to contraindications. To aid in the completion of the form, guidelines are available online, providing clear instructions for parents and healthcare providers. Ultimately, the 680 form serves as a vital tool in promoting public health and safeguarding the well-being of children in educational settings.

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

Documents used along the form

The Florida Certification of Immunization, known as the 680 form, is an important document for ensuring that children meet the necessary immunization requirements for school attendance. Along with this form, several other documents may be needed to provide a complete picture of a child's health and immunization status. Below are some commonly used forms and documents that often accompany the 680 form.

  • DH Form 150-615: This form provides immunization guidelines specifically for Florida schools, childcare facilities, and family daycare homes. It offers detailed instructions on how to complete the 680 form and ensures that parents and guardians understand the immunization requirements for their children.
  • Temporary Medical Exemption Form: This document is used when a child cannot receive certain vaccinations due to medical reasons. It requires a healthcare provider's signature and must include an expiration date, indicating when the exemption will be reviewed or expire.
  • Permanent Medical Exemption Form: Similar to the temporary exemption, this form is for children who are permanently exempt from vaccinations due to medical contraindications. It must be filled out by a healthcare provider and should clearly state the medical reasons for the exemption.
  • Arizona Board of Nursing License Form: This official document is necessary for those seeking to obtain or renew a nursing license in Arizona, outlining the required steps and regulations. For more information, visit azformsonline.com/arizona-board-of-nursing-license.
  • Immunization Records: These are official documents that detail a child's vaccination history. They may be provided by healthcare providers and should include the dates of all vaccinations received. This record helps verify that a child has met the immunization requirements outlined in the 680 form.

Understanding these forms and documents is essential for parents and guardians to ensure their children are adequately protected and compliant with school immunization requirements. Proper documentation not only supports the health of the child but also contributes to the overall well-being of the community.

Key takeaways

When filling out and using the Florida Certification of Immunization Form (680), keep these key takeaways in mind:

  • Understand the Purpose: This form certifies that a child has received the necessary immunizations required for school attendance in Florida.
  • Gather Information: Collect all relevant information before starting, including the child's full name, date of birth, and immunization records.
  • Complete All Sections: Make sure to fill in all appropriate doses and dates for each vaccine listed on the form.
  • Use the Correct Certificate: Sign and date the appropriate certificate (A, B, or C) based on the child's immunization status.
  • Temporary Exemptions: If a child has not completed their immunizations, use Part B for temporary exemptions, but remember to include an expiration date.
  • Permanent Exemptions: Use Part C for permanent medical exemptions, providing valid clinical reasoning for each exemption.
  • Consult Guidelines: Refer to the Immunization Guidelines available at www.immunizeflorida.org/schoolguide.pdf for detailed instructions.
  • Check for Accuracy: Review all entries for accuracy. Mistakes can lead to delays in school enrollment.
  • Keep Copies: Always keep a copy of the completed form for your records and for future reference.
  • Stay Informed: Be aware of any changes in immunization requirements, especially for different grade levels.

Form Overview

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 that a child has received the necessary immunizations required for school attendance in Florida.
Immunization Records Parents or guardians must provide details of all vaccine doses and dates, ensuring the child's immunization records are complete.
Exemption Options The form includes options for temporary and permanent medical exemptions for children unable to receive certain vaccines.

Frequently Asked Questions

What is the purpose of the Florida 680 form?

The Florida 680 form, also known as the Certification of Immunization, serves as a record of a child's immunizations. It is required for school attendance in Florida, ensuring that children are vaccinated against certain diseases as mandated by state law. This form is essential for both public and private school enrollment, as well as for daycare and childcare facilities.

Who needs to complete the 680 form?

The 680 form must be completed for children entering kindergarten, preschool, or any grade level from 1 through 12 in Florida schools. It is also necessary for children attending daycare or family daycare homes. Parents or guardians are responsible for providing accurate immunization records on this form.

What information is required on the 680 form?

The form requires several key pieces of information, including:

  • Child's full name (last name, first name, middle initial)
  • Date of birth
  • Parent or guardian's name
  • Child's Social Security number (optional)
  • State immunization ID number (optional)
  • Details of immunizations received, including vaccine type, doses, and dates

Additionally, the form includes sections for certifying the completion of immunizations, temporary medical exemptions, and permanent medical exemptions.

How do I fill out the 680 form?

To fill out the 680 form, start by entering the child's personal information at the top of the form. Next, document all appropriate vaccine doses and their corresponding dates in the designated areas. After completing the form, the parent or guardian must sign and date the appropriate certification section (A, B, or C) to confirm the accuracy of the information provided.

What are the different certification sections on the form?

The 680 form includes three certification sections:

  1. Part A: Confirms that the child has received all required immunizations for K-12, excluding specific middle school requirements.
  2. Part B: Used for children who have not completed their immunizations but have started the process. This section is valid only with an expiration date.
  3. Part C: For children with permanent medical exemptions, where a physician must provide valid clinical reasoning for the exemption.

Where can I find additional information about the 680 form?

Additional information and guidelines for completing the 680 form can be found on the Florida Department of Health's website. The specific document, DH Form 150-615, provides comprehensive instructions regarding immunization requirements for schools, childcare facilities, and family daycare homes. Access it at www.immunizeflorida.org/schoolguide.pdf .

What should I do if my child is not fully immunized?

If your child is not fully immunized, you should complete Part B of the 680 form. This indicates that your child has started the immunization process and outlines the schedule for completing the required vaccinations. It is crucial to keep track of all immunizations and to ensure that additional doses are administered as needed. Consult with your healthcare provider to determine the best course of action.

Misconceptions

  • Misconception 1: The 680 form is only for K-12 students.
  • This form is often thought to be limited to K-12 students. However, it also applies to children in daycare, preschool, and kindergarten. The form accommodates various educational settings, ensuring that all children receive the necessary immunizations.

  • Misconception 2: Parents must provide a Social Security number.
  • Some believe that providing a child's Social Security number is mandatory on the 680 form. In fact, it is optional. Parents can choose to leave this section blank without any repercussions.

  • Misconception 3: The form only requires immunization dates.
  • While the 680 form does require the dates of immunizations, it also asks for the specific vaccines administered. Parents must ensure that they fill out both the dates and the types of vaccines received.

  • Misconception 4: A temporary medical exemption is permanent.
  • Some individuals mistakenly think that a temporary medical exemption lasts indefinitely. In reality, it has an expiration date and must be renewed or updated as necessary. This ensures that medical conditions are re-evaluated over time.

  • Misconception 5: All vaccines are required for school attendance.
  • Not all vaccines are mandatory for every grade level. The requirements vary by age and grade, particularly for middle school students. Parents should check the specific requirements for their child's grade to ensure compliance.

  • Misconception 6: The 680 form is the only document needed for school enrollment.
  • Many believe that submitting the 680 form is sufficient for school enrollment. However, schools may require additional documentation, such as proof of residency or other health records, depending on their policies.

  • Misconception 7: The form can be completed without a healthcare provider.
  • Some think they can fill out the form independently without consulting a healthcare provider. However, it is essential to have a healthcare professional verify and sign the document to ensure accuracy and compliance with state regulations.

  • Misconception 8: Immunization records can be outdated.
  • There is a belief that immunization records do not need to be current. In fact, schools require up-to-date records to ensure that children are protected against preventable diseases. Parents should regularly check their child’s immunization status and update the form as needed.