Dh Form 684 - Immunization Annual Report Of Compliance For Kindergarten And Seventh Grade

Download a blank fillable Dh Form 684 - Immunization Annual Report Of Compliance For Kindergarten And Seventh Grade in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Dh Form 684 - Immunization Annual Report Of Compliance For Kindergarten And Seventh Grade with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

Rick Scott
Mission:
Governor
To protect, promote & improve the health
of all people in Florida through integrated
John H. Armstrong, MD, FACS
state, county & community efforts.
State Surgeon General & Secretary
Vision: To be the Healthiest State in the Nation
IMMUNIZATION ANNUAL REPORT OF COMPLIANCE FOR KINDERGARTEN
AND SEVENTH GRADE
COMPULSORY IMMUNIZATION - FLORIDA STATUTES 1003.22
(A) Private School Information:
Date: __________
Name of School:
Information on the person completing this form:
Address:
Name:
City
Zip
County
Position/Agency:
Name of Principal:
Phone Number:
(B) Student Information
: List students who are not fully immunized. Indicate type of exemption or out of compliance.
Exemptions expiring before the date on this form are out of compliance.
Medical Exemptions
30-Day
Temporary
Transfer
Religious
Out of
Permanent
DH-680
Exemptions
Grade
Name
Exemption
Compliance
DH-680
(Part B)
DH-681
List Enrollment
(Part C)
List Expiration
(Last, First)
Date
Date
th
K
or 7
th
K
or 7
th
K
or 7
th
K
or 7
th
K
or 7
th
K
or 7
th
K
or 7
th
K
or 7
th
K
or 7
th
K
or 7
(C) Summary Information:
.
Provide the total number of students in each category
Medical Exemptions
Fully
Students
Religious
30-Day
Out of
Immunized
Temporary
Permanent
Enrolled in
Exemption
Transfer
Grade
DH-680
Compliance
DH-680
DH-680
Grade
DH-681
Exemptions
(Part B)
(Part C)
(Part A)
Kindergarten
Seventh
Submit to the local county health department by October 1:
Attention CHD: Type or enter CHD name,
address, phone, fax, and contact person,
PRIOR TO copying and distributing this form.
DH Form 684
Florida Department of Health
TWITTER:HealthyFLA
Division of Disease Control and Health Protection
FACEBOOK:FLDepartmentofHealth
Bureau of Communicable Diseases • Immunization Section
YOUTUBE: fldoh
4052 Bald Cypress Way, Bin A-11 • Tallahassee, FL 32399-1719
FLICKR: HealthyFla
PHONE: 850/245-4342 • FAX 850/922-4195
PINTEREST: HealthyFla

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Form 61a200(q) - Supplemental Report Of Operations For Contained And Residential Landfills Form 61a200(q) - Supplemental Report Of Operations For Contained And Residential Landfills Financial
Form 61a200(q) - Supplemental Report Of Operations For Contained And Residential Landfills - 2008 Form 61a200(q) - Supplemental Report Of Operations For Contained And Residential Landfills - 2008 Financial
Form 61a200(q) - Supplemental Report Of Operations For Contained And Residential Landfills Form 61a200(q) - Supplemental Report Of Operations For Contained And Residential Landfills Financial
Form Ld-t - Annual Report Of Premiums,taxes And Fees Of Foreign Life And Accident And Health Insurance Companies - 2011 Form Ld-t - Annual Report Of Premiums,taxes And Fees Of Foreign Life And Accident And Health Insurance Companies - 2011 Financial
Form Rrg-t - Annual Report Of Premiums,taxes,and Fees Of Registered Risk Retention Groups - 2011 Form Rrg-t - Annual Report Of Premiums,taxes,and Fees Of Registered Risk Retention Groups - 2011 Financial
Form St-340 - Annual Report Of Sales And Use Tax Exemptions Claimed By Agent/project Operator Of Industrial Development Agency/authority (ida) Form St-340 - Annual Report Of Sales And Use Tax Exemptions Claimed By Agent/project Operator Of Industrial Development Agency/authority (ida) Financial
Form Ar 12/97 - Annual Report Of Project For Capital Credit - Alabama Department Of Revenue 2007 Form Ar 12/97 - Annual Report Of Project For Capital Credit - Alabama Department Of Revenue 2007 Financial
Form Nyc-fp - Annual Report Of Fire Premiums Tax Upon Foreign And Alien Insurers - 2016 Form Nyc-fp - Annual Report Of Fire Premiums Tax Upon Foreign And Alien Insurers - 2016 Financial
Form 1223 - Michigan Annual Report Of Unclaimed Cash And/or Safe Deposit Boxes - 2012 Form 1223 - Michigan Annual Report Of Unclaimed Cash And/or Safe Deposit Boxes - 2012 Financial
Form Cl-4 - Annual Report Of Electric Cooperative Corporation Property And Gross Receipts - 2010 Form Cl-4 - Annual Report Of Electric Cooperative Corporation Property And Gross Receipts - 2010 Financial

Related Categories

Parent category: Legal
Download
Go