Get Florida Certification Of Immunizationlegal Authority Sections 1003 22 402 305 402 313 Florida

FLORIDA CERTIFICATION OF IMMUNIZATION Legal Authority Sections 1003. 22 402. 305 402. 313 Florida Statutes Rule 64D-3. 046 Florida Administrative Code LAST NAME PARENT OR GUARDIAN FIRST NAME CHILD S SS Optional MI DOB MM/DD/YYYY STATE IMMUNIZATION ID Directions Enter all appropriate doses and dates below. Sign and date appropriate certificate A B or C on form* For additional information See Immunization Guidelines Florida Schools Childcare Facilities and Family Daycare Homes for information and instructions on form completion and immunization requirements. Guidelines are available at www. ImmunizeFlorida*org/schoolguide. pdf* VACCINE DOE Dose 1 Dose 2 Dose 3 Dose 4 Dose 5 CODE MM/DD/YYYY MM/DD/YYYY MM/DD/YYYY MM/DD/YYYY MM/DD/YYYY DTaP/DTP A DT B Tdap Td Q Polio D Hib E MMR Combined F Separate Measles dose 1 Measles dose 2 Mumps dose 1 Mumps dose 2 I Rubella dose 1 Hepatitis B J Varicella K Varicella Disease L Year PneumoConjugate N Select appropriate box es Certificate of Immunization for K-12 Part A-Complete DOE Code 1 Check box if immunizations are complete for kindergarten entry 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 DOE Code 2 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. 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 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 Authorized Signature Issued by Date DH 680 07/2010. 046 Florida Administrative Code LAST NAME PARENT OR GUARDIAN FIRST NAME CHILD S SS Optional MI DOB MM/DD/YYYY STATE IMMUNIZATION ID Directions Enter all appropriate doses and dates below. Sign and date appropriate certificate A B or C on form* For additional information See Immunization Guidelines Florida Schools Childcare Facilities and Family Daycare Homes for information and instructions on form completion and immunization requirements. Sign and date appropriate certificate A B or C on form* For additional information See Immunization Guidelines Florida Schools Childcare Facilities and Family Daycare Homes for information and instructions on form completion and immunization requirements. Guidelines are available at www. ImmunizeFlorida*org/schoolguide. pdf* VACCINE DOE Dose 1 Dose 2 Dose 3 Dose 4 Dose 5 CODE MM/DD/YYYY MM/DD/YYYY MM/DD/YYYY MM/DD/YYYY MM/DD/YYYY DTaP/DTP A DT B Tdap Td Q Polio D Hib E MMR Combined F Separate Measles dose 1 Measles dose 2 Mumps dose 1 Mumps dose 2 I Rubella dose 1 Hepatitis B J Varicella K Varicella Disease L Year PneumoConjugate N Select appropriate box es Certificate of Immunization for K-12 Part A-Complete DOE Code 1 Check box if immunizations are complete for kindergarten entry 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.