DH Form 680 Florida Certification of Immunization PDF Details

Schools and childcare programs require the DH 680 form before children entering classes can begin attending. Staff follow FLDOH Immunization Requirements and use the form to verify that each student meets state health standards. Usually, parents or a guardian receive this record from enrolled health care providers or the County Health Department. They must then submit the form when their child joins a licensed childcare facility, family daycare home, or begins kindergarten.

Medical staff start by adding personal details about the child and the child's parent or guardian. That helps connect the record to state tracking systems and prevents mismatches in files, especially when a daycare center enrolled in Florida SHOTS shares immunization updates with public health databases. After that, providers enter vaccination dates across specific rows. Reviewers scan the timeline, checking that required doses appear in the proper order, a quiet yet effective way to prevent overlooked vaccines.

The form also outlines several certification paths:

• Part A confirms full immunization for school or childcare attendance.
• Part B allows temporary attendance while the remaining doses follow a set schedule.
• Part C is specifically for permanent medical exemptions based on valid clinical reasoning, not established religious beliefs or requests made on religious grounds.

Authorized clinic staff sign the chosen section. This form can also be certified with an electronic signature.

Parents often submit the completed record as a document receipt during registration. Schools and childcare facilities may request updates if vaccination schedules change or if new doses appear in medical records.

QuestionAnswer
Form Name DH 680 Form
Form Length 1 page
Fillable? Yes
Fillable fields 63
Avg. time to fill out 15 min
Other names form DH 680 Florida Certification of Immunization, DH 680 form Florida, DH 680 form, Florida immunization PDF

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 (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

How to Edit Form 680 Online for Free

Healthcare providers like doctors or clinic staff fill out and sign the DH 680 form, and parents or guardians usually just provide basic details and turn it in.

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Child’s Personal Info

Write the last name, first name, middle initial, and date of birth. Add the name of the parent or guardian, then include the child’s Social Security number and State Immunization ID.

Clinics and schools use these details to match records within the Florida Department of Health system, especially when a child enrolls for the first time or transfers to an additional grade.

example of blanks in form dh 680

Vaccine Information

Move to the vaccine table and enter all immunization doses the child has received. Write each vaccination date in the correct column under the matching vaccine name and code.

The form lists vaccines such as DTaP, Polio, MMR, Hepatitis B, Varicella, and pneumococcal conjugate, along with protection against illnesses like measles, diphtheria, and tetanus. Some vaccines require three doses, while others may require four doses (it depends on the child’s age and timing).

stage 2 to filling out form dh 680

Certification Section

Choose the certificate that matches the child’s immunization status.

• Part A - Complete: Mark when the child has received all required vaccines.
• Part B - Temporary: Use this option if the child still needs additional doses but has started the required schedule.
• Part C - Permanent: Complete this section when medical conditions prevent certain vaccinations. List each exempt vaccine and provide valid clinical reasoning (not covering a religious exemption).

Only one section should apply, and the healthcare provider must complete and sign it.

Entering details in form dh 680 part 3

Provider Certification Details

This part includes the physician or clinic name, authorized signature, issuing provider details, and the date of completion.

The provider’s signature confirms that the immunization information matches medical records and meets Florida health requirements.

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