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The Florida Certification of Immunization, commonly known as the 680 form, plays a crucial role in ensuring that children are vaccinated according to state requirements before they can attend school or daycare. This form is not just a simple piece of paper; it encapsulates vital information about a child's immunization history, including the specific vaccines received and the dates they were administered. Parents or guardians are required to fill out essential details such as the child's name, date of birth, and optional identifiers like the Social Security number and state immunization ID. The form includes multiple sections, allowing for the documentation of various vaccines, including DTaP, polio, MMR, and varicella, among others. It also outlines different certification options, such as confirming complete immunization, applying for temporary exemptions, or declaring permanent medical exemptions. By signing the form, healthcare providers affirm the accuracy of the information provided, thereby facilitating a smoother entry into educational settings for children. Understanding the nuances of the 680 form is essential for parents navigating the immunization landscape, as it not only meets legal requirements but also contributes to public health by ensuring that children are protected against preventable diseases.

Preview - 680 Form

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

Document Specifics

Fact Name Description
Legal Authority The 680 form is governed by Sections 1003.22, 402.305, and 402.313 of the Florida Statutes, along with Rule 64D-3.046 of the Florida Administrative Code.
Purpose This form serves as a Certification of Immunization for children attending K-12 schools and childcare facilities in Florida.
Immunization Records Parents or guardians must enter all appropriate vaccine doses and dates on the form to ensure compliance with school immunization requirements.
Exemption Options The form includes sections for temporary and permanent medical exemptions, allowing for documentation of valid medical reasons for not receiving certain vaccinations.
Signature Requirement An authorized signature from a physician or clinic is required to validate the information provided on the form.
Guidelines Access Additional information and guidelines for completing the form can be found at www.immunizeflorida.org/schoolguide.pdf.

680: Usage Instruction

Completing the 680 form is essential for documenting a child's immunization status. After filling out the form, it will be submitted to the appropriate educational institution or childcare facility. Follow the steps below to ensure all necessary information is accurately provided.

  1. Start by entering the child's last name, first name, and middle initial in the designated fields.
  2. Fill in the child's date of birth in the format MM/DD/YY.
  3. Provide the parent or guardian's name in the next section.
  4. If applicable, enter the child's Social Security Number (optional).
  5. Include the child's state immunization ID number (optional).
  6. For each vaccine listed, enter the corresponding dose dates (MM/DD/YY) for Dose 1, Dose 2, Dose 3, Dose 4, and Dose 5.
  7. Select the appropriate vaccine code for each entry from the provided list.
  8. Choose the correct certificate option (Part A, Part B, or Part C) based on the child's immunization status.
  9. If applicable, fill in the expiration date for any temporary medical exemption.
  10. For Part C, list each vaccine that has a permanent medical exemption and provide a brief explanation.
  11. Sign and date the form where indicated.
  12. Ensure that the physician or clinic name and authorized signature are included, along with the date issued.

Learn More on 680

What is the purpose of the Florida Certification of Immunization (680 form)?

The Florida Certification of Immunization, also known as the 680 form, is used to document a child's immunization history. It ensures that children meet the vaccination requirements for school attendance in Florida. The form helps schools and childcare facilities verify that children are protected against various diseases.

Who needs to complete the 680 form?

The 680 form must be completed for children entering kindergarten through 12th grade in Florida. Additionally, it is necessary for children attending daycare, family daycare homes, and preschool programs. Parents or guardians are responsible for providing accurate immunization records for their children.

What information is required on the 680 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, the form includes sections for documenting the dates of each vaccine received.

What vaccines are included on the 680 form?

The 680 form lists several vaccines that are required for school attendance. These include:

  1. DTaP/DTP
  2. Polio
  3. Diphtheria, Tetanus, and Pertussis (Tdap)
  4. Measles, Mumps, and Rubella (MMR)
  5. Hepatitis B
  6. Varicella (Chickenpox)
  7. Pneumococcal Conjugate

Each vaccine has designated doses that must be recorded on the form.

What are the different parts of the 680 form?

The 680 form has three main parts:

  • Part A: For children who have completed their immunizations for K-12.
  • Part B: For children who have started their immunization schedule but are not yet complete.
  • Part C: For children with permanent medical exemptions from certain vaccinations.

Each part requires specific documentation and signatures from authorized personnel.

How do I obtain the 680 form?

The 680 form can be obtained from a variety of sources, including:

  • Your child's healthcare provider or pediatrician
  • Local health departments
  • School districts

It is also available online through the Florida Department of Health website.

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

If your child has a medical exemption, you must complete Part C of the 680 form. This section requires a healthcare provider's signature and a valid reason for the exemption. Ensure that the exemption is documented correctly, as it is necessary for school enrollment.

Where can I find additional information about immunization requirements?

For more information on immunization requirements in Florida, you can visit the Florida Department of Health's website or refer to the Immunization Guidelines for Florida Schools, Childcare Facilities, and Family Daycare Homes. The guidelines provide detailed instructions and resources to help you understand the requirements.

Common mistakes

Completing the Florida Certification of Immunization Form 680 can be straightforward, but many individuals make common mistakes that can lead to delays or complications. Awareness of these errors can help ensure a smoother process.

One frequent mistake is incomplete personal information. People often forget to include the child’s last name, first name, or middle initial. Each section must be filled out accurately to avoid confusion or misidentification.

Another common error involves the date of birth. Incorrectly entering the date format can result in significant issues. The form requires the date to be in MM/DD/YY format, and any deviation from this can lead to rejection of the form.

Many individuals neglect to provide the parent or guardian’s information. This section is crucial as it verifies the person responsible for the child’s immunization records. Failing to include this information can hinder communication with the school or daycare.

In addition, some people mistakenly leave out the child’s Social Security number, even though it is optional. While not mandatory, including it can help with record-keeping and identification.

Another frequent oversight is not entering the correct immunization dates. Each vaccine must have its corresponding date of administration. Missing or incorrect dates can lead to confusion regarding the child’s immunization status.

Some individuals also fail to select the appropriate certificate type. There are different parts to the form (A, B, or C) based on the child’s immunization status. Choosing the wrong part can result in the form being invalid.

Additionally, people often forget to sign and date the certificate. An unsigned form is not valid, and without a date, it can create issues regarding the timeliness of the immunizations.

Another mistake is not reviewing the immunization guidelines. The form references DH Form 150-615 for detailed instructions. Not consulting these guidelines can lead to errors in completion.

Lastly, some individuals do not keep a copy of the completed form. Retaining a copy is essential for future reference and can help resolve any discrepancies that may arise later.

Documents used along the form

The Florida Certification of Immunization Form 680 is an essential document for school enrollment, ensuring that children meet immunization requirements. Along with this form, several other documents may be needed to provide a complete picture of a child's health and immunization status. Here’s a list of commonly used forms and documents that often accompany the 680 form.

  • DH Form 150-615: This is the Immunization Guidelines for Florida Schools, Childcare Facilities, and Family Daycare Homes. It provides detailed instructions on how to complete the 680 form and outlines the immunization requirements for various age groups.
  • Certificate of Medical Exemption: This document is used when a child cannot receive certain vaccinations due to medical reasons. A licensed physician must complete this certificate, explaining the medical contraindications.
  • Religious Exemption Form: Parents may opt out of immunizations for religious reasons. This form typically requires a statement affirming the religious beliefs that prevent vaccination.
  • Health History Form: Schools often request a comprehensive health history form. This document includes information about the child's past medical conditions, allergies, and any medications they may be taking.
  • Physical Examination Form: A recent physical exam is often required for school entry. This form confirms that a child has undergone a health check-up and is fit for school activities.
  • Emergency Contact Form: This document provides essential contact information for parents or guardians in case of emergencies. It ensures that the school can quickly reach someone if needed.
  • Authorization for Release of Medical Records: This form allows parents to authorize the school to access their child's medical records. It can be important for verifying immunization history.
  • School Enrollment Form: This is a general form that collects information about the child for school records. It often includes details such as the child's name, address, and previous school attended.
  • Student Health Insurance Information: Some schools require information about a child's health insurance coverage. This helps in managing health-related incidents that may occur at school.

Each of these documents plays a crucial role in ensuring that children are healthy and ready for school. Having them prepared can streamline the enrollment process and help avoid any delays.

Similar forms

The Florida Certificate of Immunization (Form 680) shares similarities with the CDC's Vaccination Record Card. Both documents serve as official records of an individual's vaccination history. The Vaccination Record Card, issued by healthcare providers, includes details about the vaccines received, including dates and types. Like the 680 form, it is used to verify immunization status for school enrollment and other activities. Both documents are critical in ensuring public health and safety, particularly in environments like schools where immunization requirements are enforced.

Another document that aligns closely with the 680 form is the Certificate of Medical Exemption. This certificate is issued when a child cannot receive certain vaccinations due to medical reasons. Similar to the 680 form's sections on temporary and permanent medical exemptions, this document requires a physician’s signature and a valid explanation for the exemption. Both documents aim to protect children’s health while ensuring compliance with immunization laws, providing a structured way to address medical contraindications.

The Immunization Information System (IIS) records, maintained by state health departments, also resemble the 680 form. IIS records compile comprehensive immunization data for individuals, tracking vaccinations throughout their lives. Like the 680 form, these records can be accessed by parents, healthcare providers, and schools to confirm vaccination status. The IIS serves as a digital counterpart to the paper documentation provided by the 680 form, enhancing accessibility and accuracy in immunization tracking.

Additionally, the School Health Assessment form is comparable to the 680 form in that both are utilized to ensure that children meet health requirements for school attendance. This assessment often includes a review of immunization status, health screenings, and physical examinations. Both forms are essential for school enrollment, focusing on safeguarding the health of students and the broader community by ensuring that children are up-to-date on their vaccinations.

Lastly, the Health Insurance Portability and Accountability Act (HIPAA) release forms bear resemblance to the 680 form regarding the sharing of medical information. While the 680 form documents immunization records, HIPAA release forms authorize healthcare providers to share an individual's health information with schools or other entities. Both documents emphasize the importance of maintaining accurate health records while ensuring compliance with legal requirements surrounding privacy and consent.

Dos and Don'ts

When filling out the Florida Certification of Immunization form (Form 680), it is crucial to approach the task with care and attention to detail. Here are five important guidelines to consider:

  • Do ensure accuracy in personal information. Double-check the child's name, date of birth, and other identifying details to prevent any errors that could delay processing.
  • Do provide complete vaccination records. Include all required doses and dates for each vaccine listed on the form. Incomplete information may result in complications.
  • Do sign and date the appropriate certificate. This step confirms that the information provided is accurate and that you acknowledge the immunization status of the child.
  • Don't leave optional fields blank if you have the information. If the child's Social Security number or State Immunization ID is available, including it can help streamline the process.
  • Don't forget to review the guidelines. Familiarize yourself with the immunization guidelines available at the specified website to ensure compliance with all requirements.

By following these guidelines, you can help ensure that the form is completed correctly and efficiently, facilitating a smoother process for your child’s school immunization requirements.

Misconceptions

  • Misconception 1: The 680 form is only required for K-12 students.
  • This form is also necessary for children in daycare, family daycare homes, and preschool settings. It covers various educational levels, not just K-12.

  • Misconception 2: Completing the 680 form guarantees school admission.
  • While the form is essential, schools may have additional requirements or policies that also need to be fulfilled for admission.

  • Misconception 3: All immunizations must be completed before submitting the form.
  • The form allows for temporary exemptions if a child is in the process of receiving their immunizations. This is outlined in Part B of the form.

  • Misconception 4: The 680 form does not need to be signed by a healthcare provider.
  • A signature from a physician or authorized clinic is required to validate the immunization records provided on the form.

  • Misconception 5: The 680 form is only for children with medical exemptions.
  • While it does include sections for medical exemptions, the form is primarily used to document immunization status for all children.

  • Misconception 6: Parents can fill out the form without any supporting documentation.
  • Parents must provide accurate immunization records to complete the 680 form properly. Documentation is crucial for verification.

  • Misconception 7: The 680 form is a one-time requirement.
  • Immunization records may need to be updated regularly, especially if a child receives additional vaccinations or changes schools.

  • Misconception 8: There is no expiration date for temporary medical exemptions.
  • Temporary exemptions must include an expiration date, making it clear when the exemption will no longer be valid.

  • Misconception 9: The 680 form can be submitted without a specific vaccine schedule.
  • The form requires documentation of the specific doses and dates for each vaccine received, ensuring that the child's immunization status is clear.

  • Misconception 10: The 680 form is not accessible to the public.
  • The form and related guidelines are available online, making it easy for parents and guardians to access the necessary information for completion.

Key takeaways

When filling out the Florida Certification of Immunization Form 680, it’s important to follow certain guidelines to ensure accuracy and compliance. Here are some key takeaways:

  • Complete Personal Information: Always enter the child’s last name, first name, middle initial, date of birth, and parent or guardian details accurately.
  • Document Immunization Doses: Fill in all appropriate doses and dates for each vaccine. Ensure that the dates are entered in the correct format (MM/DD/YY).
  • Choose the Right Certificate: Sign and date the appropriate certificate (A, B, or C) on the form. Each certificate serves a different purpose, so choose wisely based on the child's immunization status.
  • Understand Exemptions: If applicable, be aware of the options for temporary or permanent medical exemptions. These require specific documentation and reasoning.
  • Review the Guidelines: Refer to the Immunization Guidelines for Florida Schools and Childcare Facilities. This resource provides essential instructions for completing the form.
  • Verify Accuracy: Before submitting the form, double-check all entries for accuracy. Errors can lead to delays or complications in school enrollment.

Using the 680 form correctly helps ensure that children are properly immunized and ready for school. Understanding these key points can make the process smoother for everyone involved.