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Florida Medical Exemption Vaccine Form in PDF

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The Florida Medical Exemption Vaccine form serves as a critical document in the state’s immunization process for children attending school and daycare facilities. It is structured to accommodate various scenarios regarding vaccination status, including complete immunization records, temporary exemptions, and permanent medical exemptions. Parents or guardians must provide essential information such as the child’s name, date of birth, and optional social security number. The form outlines specific vaccines, allowing for the documentation of multiple doses and corresponding dates. Additionally, it includes sections for certifying that a child has received all necessary vaccinations or for indicating that a medical exemption applies due to contraindications. This exemption must be supported by valid clinical reasoning, ensuring that the health needs of the child are prioritized. The legal authority for this form is grounded in several Florida statutes and administrative rules, reinforcing its importance within the state's public health framework. For guidance on completing the form, parents can refer to the Department of Health's immunization guidelines, which provide detailed instructions on the immunization requirements for K-12 students and those in daycare settings.

Form 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)

⇩ Florida Medical Exemption Vaccine File

Document Breakdown

Fact Name Details
Legal Authority The Florida Medical Exemption Vaccine form is governed by Sections 1003.22, 402.305, and 402.313 of the Florida Statutes, as well as Rule 64D-3.046 of the Florida Administrative Code.
Purpose This form is used to document a child's immunization status for school attendance and to apply for medical exemptions.
Expiration Date Requirement For a temporary medical exemption, an expiration date must be included; otherwise, the exemption is considered invalid.
Immunization Codes The form includes specific codes for various vaccines, such as DTaP, Polio, MMR, and Varicella, which must be documented.
Sections of the Form The form is divided into three parts: Part A for complete immunizations, Part B for temporary exemptions, and Part C for permanent medical exemptions.
Physician Certification A physician or clinic must sign the form, certifying the medical condition that contraindicates immunizations for permanent exemptions.
Additional Resources Guidelines for completing the form can be found on the Florida Department of Health's website, specifically at www.immunizeflorida.org/schoolguide.pdf.
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