Florida Medical Exemption Vaccine Form PDF Details

In Florida, ensuring that children are immunized according to state guidelines is a critical step towards their admission into schools, childcare facilities, and family daycare homes. The Florida Certification of Immunization, underpinned by Sections 1003.22, 402.305, 402.313 of the Florida Statutes and Rule 64D-3.046 of the Florida Administrative Code, serves as an essential document in this process. This form meticulously records the child's name, date of birth, and the parent or guardian's details, with options to include the child's Social Security and State Immunization ID numbers. It demands the detailed entry of all administered vaccine doses and their respective dates, spanning a range of immunizations from DTaP/DTP through to Varicella and pneumococcal vaccines. The form is segmented into three significant parts: Certificate of Immunization for K-12 (Part A), Temporary Medical Exemption (Part B), and Permanent Medical Exemption (Part C), each section catering to different immunization statuses and requirements. Notably, the form allows for the documentation of temporary medical exemptions, with a mandatory expiration date, and permanent medical exemptions, where a physician must list each contraindicated vaccine along with valid clinical reasons or evidence for the exemption. This document, once completed, signed, and dated by an authorized physician or clinic, stands as a testament to a child's immunization status in alignment with Florida's public health requirements, offering a structured pathway for ensuring that immunizations are up to date or appropriately exempted for medical reasons.

QuestionAnswer
Form NameFlorida Medical Exemption Vaccine Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesreligious exemption form florida, vaccine exemption form florida, religious exemption florida dh 681 form printable, how to get form dh 681

Form Preview Example

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

(0DUFK

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)