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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 is governed by various Florida statutes and administrative rules, ensuring that children are adequately vaccinated before entering educational settings. For parents and guardians, completing this form is essential to meet school requirements; start the process by clicking the button below.

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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
DT	B
Tdap	P
Td	Q
Polio	D
Polio	D
Hib	E
Hib	E
MMR (Combined)	F
MMR (Combined)	F
(Separate)	G, H
(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	K
Varicella Disease	L
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

⇓ 680 PDF

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Similar forms

Form I-693: Report of Medical Examination and Vaccination Record - This form is used in the immigration process to document a person's medical examination and vaccination history, similar to how the 680 form certifies immunization for school attendance.
Form DH 680: Florida Certification of Immunization - This is the form itself, which certifies that a child has received the necessary vaccinations required for school entry in Florida.
Form 101: Immunization Record - This document is often used by healthcare providers to track a patient’s vaccination history, much like the 680 form tracks immunizations for school requirements.
School Health Record - Schools often maintain a health record for each student that includes vaccination status, similar to the 680 form which serves as proof of immunization.
Form CDC 731: International Certificate of Vaccination or Prophylaxis - This certificate verifies that an individual has received specific vaccinations, akin to how the 680 form certifies immunizations for school attendance.
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Form 102: Vaccine Administration Record - This form is used to document the administration of vaccines to patients, similar to how the 680 form documents immunization doses.
Form 103: Immunization Exemption Form - This form is used for parents to declare exemptions from vaccinations for their children, paralleling the exemption sections in the 680 form.
Form 104: School Entry Health Exam Form - This form is used to document a child's health examination prior to school entry, similar to the health requirements outlined in the 680 form.
Form 105: Health History Form - This document collects comprehensive health history, including immunization status, much like the 680 form focuses on vaccination records for school attendance.