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Fill Out a Valid 680 Template

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Content Overview

Guide to Writing 680

After gathering the necessary information, you will be ready to complete the Florida Certification of Immunization form, also known as Form 680. This form requires accurate details about the child's immunization history and must be signed by a physician or authorized clinic representative. Follow the steps below to ensure proper completion of the form.

  1. Begin by entering the child's last name, first name, and middle initial in the designated fields.
  2. Provide the child's date of birth in the format MM/DD/YY.
  3. Fill in the parent or guardian's name.
  4. If applicable, include the child's Social Security number and state immunization ID number in the optional fields.
  5. In the section for vaccines, enter the vaccine code and the corresponding dates for each dose received (up to five doses).
  6. Select the appropriate box for the Certificate of Immunization indicating whether the immunizations are complete for K-12 or 7th grade.
  7. If applicable, complete the Temporary Medical Exemption section by providing an expiration date.
  8. For a Permanently Medical Exemption, list each vaccine and provide valid clinical reasoning for the exemption.
  9. Have the physician or clinic representative sign the form and include their name and title.
  10. Finally, fill in the date when the form is completed.

After completing the form, it should be submitted to the appropriate school or daycare facility as required. Ensure that all information is accurate to avoid any issues with enrollment or attendance.

Document Breakdown

Fact Name Details
Legal Authority Sections 1003.22, 402.305, 402.313, Florida Statutes; Rule 64D-3.046, Florida Administrative Code govern the use of the 680 form.
Purpose The form certifies that a child has received the necessary immunizations required for school attendance in Florida.
Optional Information The child's Social Security number and state immunization ID number are optional fields on the form.
Completion Guidelines Instructions for completing the form can be found in DH Form 150-615, available at www.immunizeflorida.org/schoolguide.pdf.
Vaccine Documentation Parents must enter the dates of all vaccine doses received by the child in the designated fields.
Exemptions The form includes sections for temporary and permanent medical exemptions from immunizations.
Issuing Authority The form must be signed by a physician or authorized clinic representative to be valid.

FAQ

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 immunization status. Schools and childcare facilities in Florida require this form to ensure that children are vaccinated according to state mandates. It helps protect public health by verifying that children are up-to-date on their immunizations before attending school or daycare.

Who needs to fill out the 680 Form?

The 680 Form must be completed for any child who is entering or attending K-12 schools, daycare facilities, or family daycare homes in Florida. This includes children in preschool, kindergarten, and all grades up to 12. Parents or guardians are responsible for providing accurate immunization records for their children.

What information is required on the form?

The form requires several key pieces of information, including:

  • 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)

Additionally, you must list the vaccines received, along with the dates for each dose. This includes vaccines such as DTaP, Polio, MMR, and others.

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, excluding 7th-grade requirements.
  2. Part B: For children who have started their immunization schedule but are not yet complete. This part is valid only if it includes an expiration date.
  3. Part C: For children who have a permanent medical exemption from vaccinations. This requires a physician's signature and valid clinical reasoning for the exemption.

How do I obtain the 680 Form?

The 680 Form can be obtained from various sources. You can visit the Florida Department of Health's website, where you can download the form directly. Additionally, many healthcare providers, schools, and childcare facilities have copies available. Ensure you are using the most current version of the form to avoid any issues.

What should I do if my child has a medical exemption?

If your child has a medical exemption, you will need to complete Part C of the 680 Form. This part requires a physician's signature, along with a clear explanation of the medical reasons for the exemption. It is essential to ensure that this information is accurate and that the form is submitted to the appropriate educational institution.

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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