Blank 680 PDF Form Edit Document

Blank 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 in Florida. It is governed by various Florida statutes and administrative rules, ensuring compliance with health regulations. Parents and guardians must accurately complete this form to confirm their child's vaccinations, which is essential for enrollment in K-12 schools and childcare facilities.

To ensure your child's compliance with immunization requirements, please fill out the form by clicking the button below.

Edit Document
Jump Links

The Florida Certification of Immunization, commonly referred to as the 680 form, serves as a crucial document for parents and guardians navigating the immunization requirements for school-aged children. This form is mandated by several Florida statutes and administrative rules, ensuring that children meet the necessary vaccination standards for school attendance. It captures essential information such as the child's name, date of birth, and immunization history, including specific vaccines and their corresponding dates. The 680 form also allows for the designation of medical exemptions, either temporary or permanent, should a child be unable to receive certain vaccinations due to health reasons. Completing this form involves entering detailed vaccination data, signing the appropriate certification, and adhering to guidelines provided by the Florida Department of Health. For those seeking more information, resources are readily available online, offering guidance on how to properly fill out the form. Understanding the significance of the 680 form is vital for ensuring compliance with state regulations while safeguarding children's health and educational opportunities.

Sample - 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

Document Breakdown

Fact Name Description
Legal Authority The form is governed by Sections 1003.22, 402.305, and 402.313 of the Florida Statutes, as well as Rule 64D-3.046 of the Florida Administrative Code.
Purpose This form certifies that a child has received the necessary immunizations for school attendance in Florida.
Completion Guidelines Instructions for filling out the form can be found in DH Form 150-615, which details immunization requirements for Florida schools and childcare facilities.
Expiration of Exemptions Temporary medical exemptions must include an expiration date and are invalid without it.

Check out Other Forms

What Is an I9 - The employment verification form validates an individual's job status for external requests.

For those navigating the complexities of boat ownership, having a reliable document is key. Familiarizing yourself with the necessary requirements for an Alabama Boat Bill of Sale can significantly ease the process and ensure compliance with state regulations. For further details, visit this valuable resource.

Straight Bill of Lading Pdf - It is critical for record-keeping purposes in logistics management.

Misconceptions

Understanding the 680 form can be crucial for parents and guardians navigating the immunization requirements for school attendance in Florida. However, several misconceptions often arise regarding this important document. Here are five common misunderstandings:

  • The 680 form is only for K-12 students. Many believe this form is exclusively for children in K-12 education. In reality, it is also applicable for children in daycare, preschool, and family daycare homes.
  • Immunization records are not required for private schools. Some parents think that private institutions do not require immunization records. However, all schools, whether public or private, must adhere to state immunization laws and require the 680 form for enrollment.
  • Once the form is submitted, it never needs to be updated. It’s a common belief that the 680 form is a one-time requirement. In truth, parents must update the form as their child receives additional immunizations, particularly when moving into different school grades.
  • Medical exemptions are easy to obtain. Many assume that getting a medical exemption is straightforward. While it is possible to receive an exemption, it requires valid clinical reasoning or evidence from a physician and must be documented correctly on the form.
  • All immunizations must be completed before submitting the form. Some parents think that every immunization must be completed prior to form submission. However, the 680 form allows for partial immunization records and can indicate a schedule for completing remaining vaccinations.

By clarifying these misconceptions, parents can better navigate the immunization requirements and ensure their children are prepared for school.

Documents used along the form

The Florida Certification of Immunization Form 680 is a crucial document for ensuring that children meet the immunization requirements for school attendance. However, several other forms and documents often accompany this form to provide additional context or information regarding a child's health and immunization status. Below is a list of these commonly used documents.

  • DH Form 150-615: This form provides detailed immunization guidelines for Florida schools, childcare facilities, and family daycare homes. It outlines the requirements for immunizations and offers instructions for completing the 680 form.
  • Temporary Medical Exemption Form: Used when a child cannot receive certain vaccinations due to medical reasons, this form must specify the vaccines for which the exemption is requested and include an expiration date. It ensures that the child's immunization status is documented appropriately.
  • Permanent Medical Exemption Form: This document is for children who have permanent medical contraindications to receiving specific vaccines. It requires a physician's signature and a detailed explanation of the medical reasons for the exemption.
  • Trailer Bill of Sale: This form is vital when transferring ownership of a trailer and includes key information about the buyer, seller, and trailer details. For convenience, you can access the necessary documentation via California PDF Forms.
  • School Enrollment Form: Often required by educational institutions, this form collects essential information about the student, including their personal details and emergency contacts. It may also include sections related to health history and immunization records.
  • Health Assessment Form: This document evaluates a child's overall health and may be required by schools or childcare facilities. It often includes information on previous illnesses, allergies, and any ongoing medical treatments.
  • Vaccination Records: These records provide a comprehensive history of all vaccinations a child has received. They are essential for verifying immunization status and may be requested alongside the 680 form during school enrollment.

In summary, while the Florida Certification of Immunization Form 680 is a key component of a child's immunization documentation, it is often accompanied by several other forms and documents that collectively ensure a thorough understanding of the child's health and immunization history. Properly completing and submitting these forms is vital for compliance with state regulations and for the well-being of children in educational settings.