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Printable 680 Template

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The Florida Certification of Immunization, commonly referred to as the 680 form, plays a crucial role in ensuring that children meet the necessary immunization requirements for school attendance in Florida. This form is governed by several legal authorities, including specific sections of the Florida Statutes and the Florida Administrative Code. It serves as an official record documenting a child’s immunization history, including essential vaccines such as DTaP, Polio, MMR, and Hepatitis B. Parents or guardians are required to fill out details such as the child's name, date of birth, and immunization dates, while also providing optional information like the child's Social Security number and state immunization ID. The form includes various sections for certifying immunization status, which can indicate whether the child has completed all required doses, is temporarily exempt, or qualifies for a permanent medical exemption. Each section is designed to ensure that immunization records are accurately maintained and that children are protected against preventable diseases. For those seeking guidance on how to complete the form, additional resources are available, including the Immunization Guidelines for Florida Schools and Childcare Facilities. This comprehensive approach not only facilitates compliance with state regulations but also promotes the health and safety of children across Florida.

Common mistakes

  1. Failing to provide the child’s full name. Always include the last name, first name, and middle initial.

  2. Not entering the date of birth in the correct format. Use MM/DD/YY to avoid confusion.

  3. Leaving out the parent or guardian’s name. This is crucial for identification and contact purposes.

  4. Omitting the child’s Social Security number. While optional, providing it can help in record-keeping.

  5. Not filling in the immunization dates accurately. Each dose must have the correct MM/DD/YY format.

  6. Using incorrect vaccine codes. Ensure that each vaccine is matched with the appropriate code listed on the form.

  7. Failing to sign and date the certificate. This step is necessary for the form to be valid.

  8. Not reviewing the immunization records before submission. Ensure all doses are accounted for and documented.

  9. Neglecting to provide an expiration date for temporary medical exemptions. This is essential for compliance.

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Key takeaways

Here are some key takeaways about filling out and using the Florida Certification of Immunization Form 680:

  • Complete Information: Ensure you fill in all required fields, including the child's full name, date of birth, and parent or guardian details.
  • Immunization Records: Document all vaccine doses and dates accurately in the designated sections of the form.
  • Choose the Correct Certificate: Sign and date the appropriate certificate (A, B, or C) based on the child's immunization status.
  • Temporary Exemptions: For temporary medical exemptions, include an expiration date; otherwise, the exemption is invalid.
  • Permanently Contraindicated: If a child has a permanent medical exemption, provide valid clinical reasoning for each vaccine listed.
  • Consult Guidelines: Refer to the Florida Immunization Guidelines for detailed instructions on completing the form.
  • Submit on Time: Ensure the completed form is submitted to the appropriate school or daycare facility before the deadline.
  • Keep Copies: Always retain a copy of the completed form for your records in case it is needed in the future.

By following these guidelines, you can ensure a smooth process for your child's immunization documentation.

680 Example

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

Understanding 680

What is the purpose of the Florida 680 form?

The Florida 680 form, also known as the Certification of Immunization, serves as an official record of a child's immunizations. Schools, daycare facilities, and other educational institutions require this form to ensure that children are up-to-date on their vaccinations. This helps protect not only the individual child but also the wider community by preventing the spread of vaccine-preventable diseases.

Who needs to complete the 680 form?

The 680 form must be completed for children enrolling in K-12 schools, daycare centers, family daycare homes, and preschool programs in Florida. This includes children in grades 1 through 12, as well as those entering kindergarten. Parents or guardians are responsible for ensuring that the form is filled out accurately and submitted to the appropriate institution.

What information is required on the 680 form?

When completing the 680 form, you will need to provide the following information:

  • Child's full name (last name, first name, middle initial)
  • Date of birth
  • Parent or guardian's name
  • Child's Social Security number (optional)
  • State immunization ID number (optional)
  • Details of each vaccine received, including dates and doses

Additionally, you will need to select the appropriate certificate type (A, B, or C) based on the child's immunization status.

What are the different parts of the 680 form?

The 680 form is divided into three parts:

  1. Part A: For children whose immunizations are complete according to school requirements.
  2. Part B: For children who are in the process of receiving their immunizations but are not yet fully compliant. This part requires an expiration date for the temporary exemption.
  3. Part C: For children who have a permanent medical exemption from certain vaccines. This section requires a physician's certification stating the medical reasons for the exemption.

Where can I find more information about completing the 680 form?

For detailed instructions on how to complete the 680 form, you can refer to the Immunization Guidelines provided by the Florida Department of Health. These guidelines are available online at www.immunizeflorida.org/schoolguide.pdf . This resource offers comprehensive information on immunization requirements for schools, childcare facilities, and family daycare homes.

How to Use 680

Completing the 680 form is a straightforward process, but it requires careful attention to detail. This form is essential for documenting a child's immunization history, which is often required for school enrollment. Before you begin filling out the form, ensure you have all necessary information regarding the child's immunizations at hand. Follow these steps to accurately complete the 680 form.

  1. Begin by filling in the child's last name, first name, and middle initial in the designated fields.
  2. Enter the child's date of birth in the format MM/DD/YY.
  3. Provide the name of the parent or guardian in the appropriate space.
  4. If applicable, include the child's Social Security Number and State Immunization ID Number. These fields are optional.
  5. In the section labeled VACCINE, enter the names of the vaccines received by the child.
  6. For each vaccine listed, record the dates of administration for each dose in the format MM/DD/YY. Ensure you fill out all doses provided (up to five doses).
  7. After documenting all immunizations, select the appropriate certificate box (A, B, or C) that applies to the child's immunization status.
  8. If selecting Part A, confirm that the immunizations are complete for K-12 or 7th grade as applicable.
  9. If selecting Part B, indicate the expiration date for the temporary medical exemption.
  10. If selecting Part C, list each vaccine that is medically contraindicated and provide a valid clinical reason for the exemption.
  11. Have a physician or clinic representative sign and date the form where indicated.
  12. Finally, ensure that the form is issued by the appropriate authority and includes their signature and date.