Get FL DH Form 684 2016-2024

Students Enrolled Fully Immunized DH 680 Part A Exemption DH 681 Kindergarten Seventh Submit to the local county health department by October 1 DH Form 684 Florida Department of Health Division of Disease Control and Health Protection Bureau of Epidemiology Immunization Section 4052 Bald Cypress Way Bin A-11 Tallahassee FL 32399 PHONE 850-245-4342 FAX 850-922-4195 FloridaHealth. Rick Scott Governor Mission To protect promote improve the health of all people in Florida through integrated state county community efforts. Celeste Philip MD MPH Surgeon General and Secretary Vision To be the Healthiest State in the Nation IMMUNIZATION ANNUAL REPORT OF COMPLIANCE FOR KINDERGARTEN AND SEVENTH GRADE COMPULSORY IMMUNIZATION FLORIDA STATUTES SECTION 1003. 22 A Private School Information Date Name of School Information on the person completing this form Address Name City Zip County Name of Principal Position/Agency Phone Number B Student Information List only those students who are not fully immunized for grade. Indicate type of exemption or out of compliance. Exemptions expiring before the date on this form are out of compliance. Grade Student Name Medical Exemptions Temporary Permanent Part B Part C List Expiration 30-Day Transfer Religious Out of Exemption Exemptions DH 681 List Enrollment Date Last First K or 7th C Summary Information Provide the total number of students in each category. gov Attention CHD Add CHD contact information PRIOR to copying and distributing. Be sure to include a telephone number. Rick Scott Governor Mission To protect promote improve the health of all people in Florida through integrated state county community efforts. Celeste Philip MD MPH Surgeon General and Secretary Vision To be the Healthiest State in the Nation IMMUNIZATION ANNUAL REPORT OF COMPLIANCE FOR KINDERGARTEN AND SEVENTH GRADE COMPULSORY IMMUNIZATION FLORIDA STATUTES SECTION 1003. Celeste Philip MD MPH Surgeon General and Secretary Vision To be the Healthiest State in the Nation IMMUNIZATION ANNUAL REPORT OF COMPLIANCE FOR KINDERGARTEN AND SEVENTH GRADE COMPULSORY IMMUNIZATION FLORIDA STATUTES SECTION 1003. 22 A Private School Information Date Name of School Information on the person completing this form Address Name City Zip County Name of Principal Position/Agency Phone Number B Student Information List only those students who are not fully immunized for grade. 22 A Private School Information Date Name of School Information on the person completing this form Address Name City Zip County Name of Principal Position/Agency Phone Number B Student Information List only those students who are not fully immunized for grade. Indicate type of exemption or out of compliance. Exemptions expiring before the date on this form are out of compliance. Indicate type of exemption or out of compliance. Exemptions expiring before the date on this form are out of compliance. Grade Student Name Medical Exemptions Temporary Permanent Part B Part C List Expiration 30-Day Transfer Religious Out of Exemption Exemptions DH 681 List Enrollment Date Last First K or 7th C Summary Information Provide the total number of students in each category.