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Get FL DH 680 2010

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. 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 DH 680 Jul 2010 Stock Number 5740-000-0680-6 Authorized Signature Issued By Date. 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 PARENT OR GUARDIAN CHILD S SS optional MI DOB MM/DD/YY STATE IMMUNIZATION ID optional Directions Enter all appropriate doses and dates below. immunizeflorida*org/schoolguide. pdf* VACCINE DTaP/DTP DT Tdap Td Polio Hib MMR Combined Separate DOE CODE A B P Q D E F G H I Hepatitis B Varicella Varicella Disease J K L PneumoConju Dose 1 Dose 2 Dose 3 Dose 4 Measles dose 1 Mumps dose 1 Rubella dose 1 N Dose 5 Year Select appropriate box es Certificate of Immunization for K-12 Part A-Complete DOE Code 1 Immunizations are complete K-12 Excluding 7th grade/middle school requirements 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. 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 PARENT OR GUARDIAN CHILD S SS optional MI DOB MM/DD/YY STATE IMMUNIZATION ID optional Directions Enter all appropriate doses and dates below. immunizeflorida*org/schoolguide. pdf* VACCINE DTaP/DTP DT Tdap Td Polio Hib MMR Combined Separate DOE CODE A B P Q D E F G H I Hepatitis B Varicella Varicella Disease J K L PneumoConju Dose 1 Dose 2 Dose 3 Dose 4 Measles dose 1 Mumps dose 1 Rubella dose 1 N Dose 5 Year Select appropriate box es Certificate of Immunization for K-12 Part A-Complete DOE Code 1 Immunizations are complete K-12 Excluding 7th grade/middle school requirements 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. .

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