IMMUNIZATION ANNUAL REPORT OF COMPLIANCE FOR KINDERGARTEN AND SEVENTH GRADE

COMPULSORY IMMUNIZATION - FLORIDA STATUTES 232.032

1.

?

________________________________________

4. Kindergarten ______ Seventh Grade ________

8. _________________________________

Name of School

( Please check only one grade)

Date

2.

?

________________________________________

5. ________________________________________

9. _________________________________

Address

Person Completing Report

Total Enrollment

________________________________________

6. ________________________________________

10. Total Fully Immunized ____________

City County Zip

Position/Agency of Person Completing Report

Have DH-680 (Part A-1 or A-2)

Those without are to be listed below.

3.

?

________________________________________

7. ________________________________________

Name of Principal

Phone Number of Person Completing Report

11. List Students with Medical and Religious Exemptions, or 30 Day Transfer Exemptions - - Check and/or complete categories.

(A)

(B)

(C)

(D)

(E)

(F)

(G)

Medical Exemptions

Religious

Exemptions

DH-681

30 Day Transfer

Exemptions

(List

Parent's or Guardian's Name

Address

Telephone

Number

Name

Temporary

Permanent

DH-680

DH-680

(Part B)

(Part C)

Enrollment

(List Date)

Expiration

Date)