florida immunization form.pdf - FLORIDA CERTIFICATION OF...

DH 680 (Jul 2010) Stock Number: 5740-000-0680-6
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:
x Enter all appropriate doses and dates below.
x Sign and date appropriate certificate (A, B, or C) on form.
x 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 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 appropriate box(es)
Certificate of Immunization for K-12
Part A-Complete