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Fillable 680 Template

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Content Overview

File Details

Fact Name Description
Legal Authority The form is governed by Sections 1003.22, 402.305, and 402.313 of the Florida Statutes, along with Rule 64D-3.046 of the Florida Administrative Code.
Purpose This form certifies that a child has received the required immunizations for school attendance in Florida.
Completion Instructions Parents or guardians must enter all appropriate doses and dates of immunizations and sign the relevant certificate (A, B, or C).
Optional Information Children’s Social Security Number and State Immunization ID Number are optional but can be included on the form.
Temporary Medical Exemption Part B allows for a temporary medical exemption, which is invalid without an expiration date.
Permanently Medically Exempt Part C outlines the process for claiming a permanent medical exemption, requiring documentation of contraindications.
Additional Resources Guidelines for completing the form are available at www.immunizeflorida.org/schoolguide.pdf.

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

Common mistakes

Filling out the Florida Certification of Immunization form, also known as the 680 form, can be a straightforward process, but there are common mistakes that can lead to delays or complications. One frequent error is incomplete information. Many individuals neglect to fill in all required fields, such as the child's last name, first name, and date of birth. Missing this basic information can result in the form being returned for correction, which can be frustrating and time-consuming.

Another common mistake involves incorrect dates. When entering vaccination dates, it is crucial to ensure that they are accurate and formatted correctly (MM/DD/YY). Errors in dates can raise questions about the validity of the immunization records, potentially leading to issues with school enrollment or daycare admission.

Some people fail to sign the form or provide the necessary certification. The form requires an authorized signature, and without it, the submission may be considered invalid. It is essential to double-check that all signatures are present before submitting the form to avoid unnecessary delays.

Additionally, individuals often overlook the importance of choosing the correct certificate part. There are different sections for temporary medical exemptions, permanent medical exemptions, and completion of immunizations. Selecting the wrong part can misrepresent the child's immunization status and create complications in their school or daycare application.

Another frequent oversight is failing to include the physician or clinic name. This information is vital for verifying the authenticity of the immunization records. Without it, the form may be deemed incomplete or untrustworthy, causing delays in processing.

Moreover, some parents or guardians do not provide the expiration date for temporary medical exemptions. This date is crucial, as it indicates how long the exemption is valid. Without this detail, the exemption cannot be processed correctly, which could lead to the child being required to receive vaccinations sooner than anticipated.

Finally, it is essential to remember that not reviewing the guidelines can lead to mistakes. The guidelines provide specific instructions on how to fill out the form correctly. Failing to consult these resources may result in errors that could have been easily avoided. Taking the time to understand the requirements can save significant hassle in the long run.

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