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Ensuring children are properly immunized against various diseases before attending school or daycare is a critical aspect of public health efforts in Florida. The DH 680 form, known as the Florida Certification of Immunization, serves as a standardized document to verify that a child has received the vaccinations required by state law for school attendance. This legal document, outlined by Sections 1003.22, 402.305, and 402.313 of the Florida Statutes, along with Rule 64D-3.046 of the Florida Administrative Code, meticulously records each vaccine dose, including dates administered, under the supervision of a healthcare provider or clinic. Besides covering the complete schedule of immunizations for K-12 students, the form accommodates special circumstances through its sections. For children-in-transition or those with specific medical conditions, it includes provisions for temporary or permanent medical exemptions. Further guidance on completing this crucial document is detailed in the DH Form 150-615, Immunization Guidelines - Florida Schools, Childcare Facilities and Family Daycare Homes, accessible through the state's immunization website. This ensures that the process, while thorough, is navigable for parents, guardians, and healthcare providers alike.

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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

File Characteristics

Fact Number Detail
1 Form Name: Florida Certification of Immunization
2 Legal Authority: Sections 1003.22, 402.305, 402.313, Florida Statutes; Rule 64D-3.046, Florida Administrative Code
3 Required Information: Last Name, First Name, Middle Initial, Date of Birth, Parent or Guardian, Child's Social Security Number (optional), State Immunization ID# (optional)
4 Documented Vaccines: DTaP/DTP, Tdap, Td, Polio, Hib, MMR, Measles, Mumps, Rubella, Hepatitis B, Varicella, Pneumococcal Conjugate
5 Certificate Types: Part A - Complete for K-12 minus 7th grade requirements; Part B - Temporary for incomplete immunizations; Part C - Permanent for medically contraindicated immunizations
6 Guidelines Reference: DH Form 150-615, Immunization Guidelines - Florida Schools, Childcare Facilities, and Family Daycare Homes (July 2010)
7 Guidelines Availability: Can be accessed at www.immunizeflorida.org/schoolguide.pdf
8 Form Identification: DH 680 (Jul 2010) Stock Number: 5740-000-0680-6

Steps to Writing 680

Filling out the Florida Certification of Immunization, known as the 680 form, is a critical step in ensuring children are ready for school, childcare, and other community activities. The form is designed to document a child's immunizations, aligning with the state's health requirements. Before starting, it's advisable to have the child's immunization records on hand, along with information about the parent or guardian, and, if applicable, the child's social security and state immunization ID numbers. The form will require details about each vaccine administered, including the dates of the doses.

To accurately complete the form, follow these steps:

  1. On the top section of the form, fill in the child's last name, first name, middle initial (MI), Date of Birth (DOB) in MM/DD/YY format, the parent or guardian's name, and if available, the child's social security number (SS#) and state immunization ID number. Both SS# and state immunization ID number are optional.
  2. Refer to the vaccine table provided on the form. Enter the dates for each dose received of the listed vaccines, such as DTaP/DTP, Polio, MMR, Hepatitis B, and Varicella, among others.
  3. For the section labeled "Select appropriate box(es)," choose the certificate that applies to the child's situation:
    • Part A for general K-12 immunizations (excluding specific 7th grade/middle school requirements)
    • Part B for temporary medical exemptions
    • Part C for permanent medical exemptions
  4. For Part A, if applicable, check the appropriate box (DOE Code 1 or DOE Code 8) to indicate the child's immunizations are complete as per the required educational level.
  5. In Part B, fill in the temporary medical exemption expiration date, if applicable, and check DOE Code 2 to certify that the child has started but not yet completed the immunization schedule.
  6. For Part C, list each medically contraindicated vaccine along with the valid clinical reasoning or evidence for the exemption. Check DOE Code 3 to certify this condition.
  7. At the bottom of the form, provide the Physician or Clinic Name and the authorized signature. Fill in the name of the person issuing the form and the date it is issued.

Ensure all information is accurate and legible. Once completed, this document will serve as a formal record of the child's immunization status, meeting legal and educational institution requirements in Florida.

Important Details about 680

What is the DH 680 form used for?

The DH 680 form, also known as the "Florida Certification of Immunization," is a document required in Florida for documenting a child's immunization records. This form is necessary for enrollment in schools, childcare facilities, and family daycare homes within the state, serving as official proof that the child has received all the required vaccinations.

Where can I obtain the DH 680 form?

This vital form can be obtained from your child's healthcare provider or the local health department. These entities are authorized to complete and sign the form, ensuring that it meets the requirements set forth by Florida law and regulations.

Can the DH 680 form be completed online?

At this time, the DH 680 form cannot be completed online due to the necessity of an authorized healthcare provider's signature verifying the immunization records. However, electronic records maintained by healthcare providers or local health departments may facilitate the process of obtaining a completed form.

What information is required on the DH 680 form?

The form requires detailed information about the child's immunization history, including doses of vaccines and the dates they were administered. Additionally, personal information such as the child's name, date of birth, and the parent or guardian's details are needed to accurately identify the immunization record. A healthcare provider must review these records and sign the form, certifying its accuracy.

What are parts A, B, and C on the DH 680 form?

Part A is completed when a child is fully up to date with their immunizations, barring 7th-grade requirements. Part B covers temporary medical exemptions, used when a child has started but not yet completed the full immunization schedule. Part C is for permanent medical exemptions, indicating specific vaccines that are medically contraindicated for the child, with each vaccine and the reasoning needing to be listed.

How do I obtain a medical exemption through the DH 680 form?

For a medical exemption, a healthcare provider must certify that certain immunizations are medically contraindicated for the child. This information is detailed in Part C of the form, where the provider lists the specific vaccines and provides valid clinical reasoning or evidence for the exemption.

Is the child's Social Security number required on the DH 680 form?

Providing the child's Social Security number on the DH 680 form is optional. The form also allows for the inclusion of a state immunization ID number, which can serve as an alternative identifier for maintaining and accessing the child's immunization records.

How long is the DH 680 form valid?

The validity of the DH 680 form typically corresponds with the timing of required booster shots or any updates to a child's immunization schedule. Temporary medical exemptions (Part B) include an expiration date, by which further immunization or an update to the form is necessary. Permanent medical exemptions (Part C) do not expire but should be updated as needed based on the child's health status.

Who can sign the DH 680 form?

The DH 680 form must be signed by a healthcare provider who is authorized to administer vaccines. This includes physicians, nurse practitioners, and other clinic or health department staff designated to manage immunization records and validate that the child has received the required vaccinations according to Florida's guidelines.

Common mistakes

Filling out the DH 680 form, the Florida Certification of Immunization, is a critical step for parents and guardians ensuring their child meets the state's school and childcare vaccination requirements. However, there are common mistakes that can lead to confusion, delays, or even the rejection of the form. Understanding these pitfalls can help streamline the process.

One prevalent mistake is incorrect or incomplete information in the personal details section. This includes, but is not limited to, the child's name, date of birth (DOB), and the parent or guardian's information. Forgetting to enter the child’s Social Security Number (SSN) and state immunization ID# may not seem major since they are optional, but doing so can potentially expedite the verification process.

Another error involves vaccine codes and dates. The form requires precise documentation of each dose including the date administered (MM/DD/YY). Confusion or inaccuracies in this section, such as mixing up vaccine codes (i.e., DTaP/DTP, Tdap, Td) or entering incorrect dates, can lead to significant issues in verifying the immunization status.

Not correctly selecting the certificate type (A, B, or C) that best describes the child’s immunization status is another stumbling block. Each part of the form serves a different purpose, and choosing the wrong section can lead to unnecessary complications. For example, selecting Part A when the child's immunizations are incomplete misrepresents their status and can lead to compliance issues.

Many overlook the necessity of the temporary medical exemption expiration date in Part B. This oversight makes this part of the form invalid, which can affect children in daycare or those who are in the process of completing their immunizations. Similarly, for Part C, failing to list each medically contraindicated vaccine along with valid clinical reasoning or evidence for exemption affects the child's immunization records.

The underutilization of the guidelines provided by the Florida Department of Health is another common mistake. These guidelines are meant to simplify the completion process, offering clear instructions that can prevent most of the above errors. Ignorance of these resources results in unnecessary mistakes.

Lastly, the omission of the physician or clinic’s name and signature, as well as the issuer’s information and date, compromises the document's validity. This critical information verifies the authenticity of the immunization data and is mandatory for the form to be accepted. Without it, the certification of immunization remains incomplete, rendering it inapplicable for school, childcare facilities, and family daycare homes enrollment.

In conclusion, avoiding these pitfalls when filling out the DH 680 form will greatly assist in ensuring that the process is smooth and error-free. Paying close attention to detail, carefully reviewing each section, and utilizing available guidelines and resources are key steps in successfully completing and submitting this vital document.

Documents used along the form

When handling the Florida Certification of Immunization, also known as the DH 680 form, various other documents are often required to provide a comprehensive view of an individual’s health history and status. These additional forms ensure that all necessary health information is accurately recorded and easily accessible for schools, childcare facilities, and healthcare providers.

  • Birth Certificate: It's essential for verifying the child's age and identity. This document ensures the information on the DH 680 form matches the official records.
  • Physical Examination Form: Schools and some childcare facilities require a physical exam to ensure a child is fit for attendance and participation in activities, highlighting any special needs or precautions.
  • Exemption from Immunization Form: For those that qualify, this document records any exemptions from vaccinations due to medical, religious, or philosophical reasons, providing legal proof of such exemptions.
  • DH 3040 Form - School Entry Health Exam: This form, completed by a healthcare professional, is another requirement for school entry, detailing the child's overall health status and any notable conditions.
  • Medication Administration Form: If a child needs to take medication during school hours, this document, filled out by a parent or guardian and a healthcare provider, outlines the necessary details and permissions for administering medicine.
  • Vaccine Information Statements (VIS): Provided every time a vaccine is administered, these sheets inform about the benefits and risks of the vaccines, serving as a record that the information was shared with the patient or guardian.

These documents, used alongside the DH 680 form, create a protective and informed environment. They help ensure that individuals attending schools and childcare facilities in Florida are both healthy and safely accommodated, according to their unique health needs and legal requirements.

Similar forms

The Vaccine Information Statement (VIS) shares similarities with the Florida Certification of Immunization (DH 680 form) as both documents aim to inform about vaccines. The VIS provides details about the benefits and risks associated with vaccinations, serving an educative role similar to that of the 680 form's purpose to document and verify immunization for school attendance. Both are integral to public health initiatives, ensuring individuals and guardians are well-informed about immunizations, albeit serving different phases of the vaccination process.

The Medical Exemption Form parallels the DH 680 form through its provision to exempt individuals from vaccinations due to medical reasons. Both documents require certification by a healthcare provider to validate the exemption or immunization status. While the 680 form includes sections for temporary and permanent medical exemptions, the Medical Exemption Form is entirely dedicated to documenting these instances, emphasizing the medical necessity and specific conditions that contraindicate vaccinations.

A School Enrollment Form, like the DH 680 form, is essential for the school admission process in many states, including Florida. The enrollment form captures basic student information and educational history, and often requires proof of immunization, which the 680 form directly supports. By ensuring that immunization records are completed and up-to-date, the 680 form plays a crucial role in fulfilling enrollment requirements, safeguarding school communities against vaccine-preventable diseases.

The International Certificate of Vaccination or Prophylaxis (ICVP) shows similarities with the DH 680 form in its role as an official record of vaccination, though for international travel rather than school enrollment. Both documents verify that the bearer has received specific vaccines, crucial for public health safety. The ICVP is often required for entry into countries where certain diseases are prevalent, mirroring the 680 form's requirement for school attendance to prevent disease outbreaks.

Lastly, the Immunization Registry Consent Form parallels the DH 680 form by involving the documentation and sharing of an individual's vaccination records. Consent forms allow for the inclusion of personal immunization information in state or local immunization registries, facilitating healthcare providers' access to vaccination histories. Similarly, the DH 680 form serves as a record of immunizations for schools, enhancing disease control efforts by maintaining high vaccination rates within educational settings.

Dos and Don'ts

When filling out the Florida Certification of Immunization (DH 680 form), it's crucial to approach the task with care. This document plays a key role in ensuring school and daycare compliance with state immunization requirements. To help navigate the process, here is a list of dos and don'ts to consider:

  • Do review the Immunization Guidelines for Florida Schools, Childcare Facilities, and Family Daycare Homes (July 2010) available at www.immunizeflorida.org/schoolguide.pdf before starting the form. This guide provides valuable information on form completion.
  • Do check that all information entered on the form is accurate and legible. Mistakes or unreadable information can lead to unnecessary delays or complications.
  • Do include all relevant doses and dates for the vaccines listed. This ensures the form is completed in full and can expedite processing.
  • Do sign and date the appropriate certificate (A, B, or C) on the form, as this is a necessary step for validation.
  • Do not leave sections blank. If a section does not apply or if certain information is optional and you choose not to include it, make sure to mark it clearly as “N/A” or “Not Applicable.”
  • Do not guess vaccine dates or information. If you're uncertain, consult the child's medical records or reach out to their healthcare provider for accurate information.
  • Do not use pencil or erasable ink when filling out the form. Information should be permanent to prevent alterations.
  • Do not ignore the expiration date for a temporary medical exemption documented in Part B. This date is crucial and ensures that records are kept up to date for compliance with state laws.

Following these guidelines will help in the accurate and timely completion of the DH 680 form, ensuring compliance with Florida's immunization requirements for school and daycare attendance. Remember, this form is a key document in safeguarding community health by verifying immunization status.

Misconceptions

Understanding Florida's Certification of Immunization (Form DH 680) is essential for accurately navigating the state's school and childcare immunization requirements. However, several misconceptions frequently arise regarding the use of this form. Clarifying these misunderstandings is crucial for parents, guardians, and healthcare professionals to ensure the wellbeing of children and compliance with Florida law.

  • Misconception 1: The Social Security number is mandatory on the form.

    While the form includes a space for the child's Social Security number, providing it is optional. This flexibility helps protect personal information and ensures privacy.

  • Misconception 2: All vaccine doses must be completed for form submission.

    The form accommodates different completion statuses, including temporary and medical exemptions, thereby not requiring all immunizations to be complete at the time of submission.

  • Misconception 3: The form only covers K-12 students.

    Although primarily used for K-12 immunization documentation, the form also applies to childcare, family daycare homes, and preschool settings, reflecting its broader applicability.

  • Misconception 4: A new form must be submitted each academic year.

    As long as a child’s immunization status remains compliant with state requirements, and no new vaccines are needed, the same form can continue to be valid across multiple years.

  • Misconception 5: Healthcare providers are the only ones who can complete the form.

    While healthcare providers commonly fill out the form, it can also be completed by any authorized representative of the Florida Department of Health, expanding the possibilities for document completion and submission.

  • Misconception 6: The form provides exemptions only for religious beliefs.

    The DH 680 form allows for medical exemptions, as clearly stated in Part C. This means that if a child has a valid medical reason, certified by a healthcare provider, they can be exempted from certain vaccines.

  • Misconception 7: Temporary medical exemptions are indefinite.

    Any temporary medical exemption indicated on the form requires an expiration date, ensuring that the child’s vaccination status will be reevaluated and adjusted as necessary.

  • Misconception 8: The form does not cover vaccines against Varicella (Chickenpox).

    The form includes spaces for documenting doses of the Varicella vaccine, as well as an indication of the disease (Varicella Disease) under specific circumstances, ensuring comprehensive immunization documentation.

Correcting these misunderstandings is essential for ensuring that children are properly immunized for their safety and the safety of others in communal settings. Moreover, it aids in the uniform application of the law and helps prevent unnecessary legal complications for families and institutions in Florida.

Key takeaways

Understanding the Florida Certification of Immunization (DH 680 form) is crucial for ensuring children are properly vaccinated for school and childcare. Here are key takeaways for filling out and using the form effectively:

  • Ensure accurate entry of the child's personal information at the top of the form, including the last name, first name, middle initial (MI), date of birth (DOB), and optionally, the child's Social Security Number (SSN) and the State Immunization ID#.
  • Vaccination records must be detailed precisely with dates for each dose administered, adhering to the vaccine codes provided on the form.
  • The form divides immunization certification into three parts: Part A for complete K-12 immunizations (excluding 7th-grade requirements), Part B for temporary medical exemptions, and Part C for permanent medical exemptions.
  • Select the appropriate certificate box (A, B, or C) based on the child's immunization status and complete the section as directed.
  • Consult the DH Form 150-615, Immunization Guidelines - Florida Schools, Childcare Facilities, and Family Daycare Homes for detailed instructions on form completion, available online.
  • For a temporary medical exemption (Part B), an expiration date is mandatory; without it, the form is invalid.
  • In the case of permanent medical exemptions (Part C), specific vaccines that are medically contraindicated must be listed along with valid clinical reasoning or evidence supporting the exemption.
  • The form must be signed by a physician, clinic, or authorized representative to validate the child’s immunization record or exemption status.
  • Keep a copy of the completed DH 680 form for your records and provide the original to the school or childcare facility as required by Florida law.

By following these guidelines, parents, guardians, and healthcare providers can ensure that the Florida Certification of Immunization (DH 680 form) is correctly filled out, thereby facilitating compliance with Florida's immunization requirements for children.

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