Florida Medical Exemption Vaccine Form – Fill Out and Use This PDF

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)