DH 680 Form – Fill Out and Use This PDF

Updated: Nov 10, 2026

The DH 680 form is a Florida Certification of Immunization document that records a child’s vaccination history. It lists each required vaccine dose and shows whether a student meets health rules for school or childcare enrollment. The form also includes sections where medical professionals confirm full immunization, add a temporary exemption with a completion schedule, or document a permanent exemption with medical reasoning.

Click the button below to fill out DH Form 680 (Florida Certification of Immunization), or download the PDF file to your device.

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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.

Question	Answer
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

How to Fill Out Form DH 680

Form DH 680 at a glance

What it is: The FLORIDA CERTIFICATION OF IMMUNIZATION, Legal Authority: Sections 1003.22, 402.305, 402.313, Florida Statutes; Rule 64D-3.046, Florida Administrative Code.

Who signs: SIGN: Physician or Clinic Name, Physician or Authorized Signature, Issued By and Date.

A filled-in Form DH 680 example: a clinic certifies a child's immunizations

Form DH 680 example filled out, example: a clinic certifies a child's immunizations — Dr. Ann Sample completes Form DH 680 for Ben Example. Ben's doses are complete, so only Part A, DOE Code 1, is ticked. The picture shows the signature, and every value in it is made up. DOE Code 8 stays empty because Ben is not in 7th grade. Part B-Temporary and Part C-Permanent stay empty because no exemption applies. The child's SS# and STATE IMMUNIZATION ID# are optional, so both stay empty. The clinic name fits on its first line, so its other lines stay empty.

How to fill out Form DH 680, box by box

The child and the parent or guardian

Enter LAST NAME, FIRST NAME, MI and DOB (MM/DD/YY).

Enter PARENT OR GUARDIAN; CHILD'S SS# (optional) and STATE IMMUNIZATION ID# (optional).

Vaccine doses

Directions: Enter all appropriate doses and dates. Sign and date appropriate certificate (A, B, orC) 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.

For each VACCINE, enter Dose 1, Dose 2, Dose 3, Dose 4 and Dose 5 as 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 and Year PneumoConju N.

Part A-Complete

Part A-Complete, DOE Code 1: Immunizations are complete K-12 (Excluding 7th grade/middle school requirements).

DOE Code 8: Immunizations are complete for 7th grade I have reviewed the records available, and to the best of my knowledge, the named child has adequately been immunized for school attendance, as documented.

Part B-Temporary

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 named child has received the immunizations documented and has commenced a schedule to complete the required immunization. Additional immunizations are not medically indicated at this time.

Part C-Permanent

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 are medically contraindicated.

SIGN

SIGN: Physician or Clinic Name, Physician or Authorized Signature, Issued By and Date.

Common questions about Form DH 680

What is a 680 form?

The FLORIDA CERTIFICATION OF IMMUNIZATION, Legal Authority: Sections 1003.22, 402.305, 402.313, Florida Statutes; Rule 64D-3.046, Florida Administrative Code. Select appropriate box(es) in Certificate of Immunization for K-12.

Sources

[1] DH 680 (Jul 2010), Florida Certification of Immunization (the Official source link on this page).