Florida Certification Of Immunization Template printable pdf download

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

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:

VACCINE

DOE

Dose 1

Dose 2

Dose 3

Dose 4

Dose 5

CODE

MM/DD/YY

DTaP/DTP

Tdap

Polio

Hib

MMR

(Combined)

(Separate)

G, H

Measles (dose 1)

Measles (dose 2)

Mumps (dose 1)

Mumps (dose 2)

Rubella (dose 1)

Rubella (dose 2)

Hepatitis B

Varicella

Varicella Disease

Year

PneumoConju

Select appropriate box(es)

Certificate of Immunization for K-12

Part A-Complete

DOE Code 1: Immunizations are complete K-12 (Excluding 7

grade/middle school requirements)

DOE Code 8: Immunizations are complete for 7

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

Florida Certification Of Immunization Template

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