Dh Form 684 PDF Details

Ensuring the health and safety of students, the DH 684 form plays a pivotal role in Florida's education system. This document is integral to tracking the immunization status of students in kindergarten and seventh grade, as mandated by Florida Statutes 1003.22. The form gathers comprehensive information regarding private school compliance with the state's immunization requirements, focusing on students who are not fully immunized and detailing the types of exemptions or non-compliance instances. Schools must list students by name, grade, and exemption type, encompassing medical, religious, temporary (30-day), and permanent exemptions, while also noting those with expired exemptions thus out of compliance. Furthermore, the DH 684 form requires schools to summarize the total number of students in each category, providing a clear snapshot of immunization rates among the student population. This summary is crucial for health authorities to identify gaps in immunization and address potential public health risks. Schools must submit this detailed annual report by October 1, highlighting the essential role of accurate record-keeping and timely reporting in safeguarding public health within educational environments.

QuestionAnswer
Form NameDh Form 684
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesdh form 150 615, get the dh 680 printable form, dh680, florida immunization record

Form Preview Example

IMMUNIZATION ANNUAL REPORT OF COMPLIANCE FOR KINDERGARTEN AND SEVENTH GRADE

COMPULSORY IMMUNIZATION - FLORIDA STATUTES 1003.22

(A) Private School Information:

 

 

 

 

 

 

 

 

 

Date

 

 

 

 

 

 

 

 

Name of School:

 

 

 

 

 

 

 

Address:

 

 

 

Information on the person completing this form:

 

 

 

 

 

 

 

 

 

 

 

 

Name:

 

 

City

County

Zip

Position/Agency:

 

 

 

 

 

 

Name of Principal:

 

 

 

Phone Number:

 

 

 

 

 

 

 

 

 

(B)Student Information: List students not fully immunized. Indicate type of exemption or out of compliance. Exemptions that expired before the date on this form are out of compliance.

 

 

 

Medical Exemptions

 

30-Day

 

 

 

 

Temporary

 

Religious

Transfer

Out of

 

 

 

DH-680

Permanent

Name

 

Grade

Exemption

Exemptions

 

(Part B)

DH-680

Compliance

 

 

 

DH-681

List Enrollment

 

 

 

List Expiration

(Part C)

 

 

 

 

 

 

(Last, First)

 

 

 

Date

 

 

 

Date

 

 

 

 

 

 

 

 

 

 

 

K

or 7th

 

 

 

 

 

 

K

or 7th

 

 

 

 

 

 

K

or 7th

 

 

 

 

 

 

K

or 7th

 

 

 

 

 

 

K

or 7th

 

 

 

 

 

 

K

or 7th

 

 

 

 

 

 

K

or 7th

 

 

 

 

 

 

K

or 7th

 

 

 

 

 

 

K

or 7th

 

 

 

 

 

 

K

or 7th

 

 

 

 

 

 

K

or 7th

 

 

 

 

 

 

K

or 7th

 

 

 

 

 

(C)Summary Information: Provide the total number of students in each category.

 

Students

Fully

Medical Exemptions

Religious

30-Day

 

 

Immunized

Temporary

Permanent

Out of

 

Enrolled in

Exemption

Transfer

Grade

Grade

Have DH Form

DH-680

DH-680

DH-681

Exemptions

Compliance

 

 

680 (Part A)

(Part B)

(Part C)

 

 

 

Kindergarten

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Seventh

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Submit by October 1, 2012 to: County Health Department

DH Form 684, 07/2012

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Filling out section 1 in form dh 860

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