FLORIDA DEPARTMENT OF EDUCATION
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STATE BOARD OF EDUCATION
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John L. Winn
Commissioner of Education
F. PHILIP HANDY,
Chairman
T. WILLARD FAIR,
Vice Chairman
Members
DONNA G. CALLAWAY
ROBERTO MARTÍNEZ
PHOEBE RAULERSON
KATHLEEN SHANAHAN
LINDA K. TAYLOR
Contact Information:
MEMORANDUM
Name:
Dianne Mennitt
Phone:
(850) 922-3727
TO:
District School Superintendents
Suncom:
292-3727
E-Mail:
dmennitt@tempest.coedu.usf.edu
FROM:
Cheri Pierson Yecke, Ph.D.
K12: 2006-139
DATE:
September 19, 2006
SUBJECT:
SCHOOL IMMUNIZATION ANNUAL REPORTS AND SURVEYS 2006-2007
The Florida Department of Education is committed to a seamless education system to provide a
safe learning environment that promotes student achievement. Section 1003.22(8), Florida
Statutes, and Rule 64D-3.011(3), Florida Administrative Code, require the Department of Health
(DOH) to collect annual reports from all public and private schools to certify compliance with the
compulsory school immunization law. The Department of Education and the Department of
Health continue to work collaboratively to provide technical assistance and support to school
districts and local health departments regarding the implementation of these requirements.
Attached for your information is a memorandum from the Florida Department of Health with four
attachments regarding Compulsory School Immunizations Annual Reports and Surveys for the
2006-2007 School Year. If you have questions or need additional information, please contact
the DOH Immunization Program Office at (850) 245-4342 or Suncom 205-4342.
Thank you for your assistance with this activity.
CPY:dm
Attachments
cc:
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Student Services Directors
MIS Directors
School Health Services Coordinators
Charles Alexander, Chief, Florida Department of Health/Bureau of Immunizations
CHERI PIERSON YECKE, PH.D.
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CHANCELLOR, K-12 PUBLIC SCHOOLS
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325 W. GAINES STREET • SUITE 514 • TALLAHASSEE, FL 32399-0400 • (850) 245-0509 • www.fldoe.org
Jeb Bush
M. Rony François, M.D., M.S.P.H., Ph.D.
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Governor
Secretary
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INTEROFFICE MEMORANDUM
DATE:
August 10, 2006
TO:
County Health Department Directors/Administrators
FROM:
Bonita J. Sorensen, M.D., M.B.A.
Deputy State Health Officer
SUBJECT:
Compulsory School Immunizations
Annual Reports and Surveys – 2006/2007 School Year
ACTION
REQUIRED:
Review and comply with standards
DUE DATE:
October 31, 2006
In October of each year, all public and private schools submit reports, in compliance with the
compulsory school immunization law, indicating the status of their kindergarten and seventh
grade students, pursuant to the requirements of section 1003.22,
Florida Statutes
, and section
64D-3.011 (3),
Florida Administrative Code
.
Public School Reporting
Electronic Reporting:
The Department of Health accepts electronic reporting from public school districts that achieved
a standard of less than five percent variance between electronic and manual reporting over a
three-year period. These school districts have adequately resolved and updated immunization
data (that is, temporary medical exemptions) into their electronic database.
•
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The list of school districts approved for electronic-only reporting of kindergarten or
seventh grade compliance will be updated annually until all school districts are reporting
data electronically (see Attachments 1 and 2).
•
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These school districts do not need to submit the Department of Health’s Immunization
Annual Report of Compliance for Kindergarten and Seventh Grade, Form 684, to the
county health department.
Manual Reporting:
County health departments are responsible for collecting Form 684. The completed forms from
public school districts with a kindergarten and/or seventh grade, not included on the attached
lists and not approved for electronic-only reporting, are due by October 1, 2006.
Private School Reporting
Private schools with a kindergarten and/or seventh grade are required to submit Form 684 to
the county health department by October 1, 2006.
Office of the Secretary
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4052 Bald Cypress Way, Bin A00
•
Tallahassee, FL 32399-1701
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County Health Department Directors/Administrators
Page Two
August 10, 2006
Method
County health departments should distribute supplies of Form 684 (sample attached) to public
and private schools with a kindergarten and/or seventh grade.
•
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Do not send Form 684 to the public school districts accepted for electronic-only
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kindergarten and seventh grade reporting (see Attachments 1 and 2).
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•
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All private schools with kindergarten and/or seventh grade should be provided with
Form 684 for manual reporting to the county health department. For a list of private
schools, visit the Non-Public Schools Directory, available on the Department of
Education’s website at http://www.fldoe.org.
•
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A separate Form 684 must be completed for each kindergarten and/or seventh grade,
and is due in the county health departments by October 1, 2006.
•
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The county health departments will summarize the data from the Form 684s on the
Department of Health’s Kindergarten and Seventh Grade Annual Report of Compliance.
•
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County health departments should complete a separate Form 685 (sample attached) for
each grade: one for kindergarten and one for seventh grade.
•
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The completed Form 685 is due October 31, 2006, and may be submitted by e-mail to
Emily_Fogarty@doh.state.fl.us
, or by U.S. mail to the Florida Department of Health,
Bureau of Immunization, 4052 Bald Cypress Way, Bin A-11, Tallahassee, Florida 32399-
1719.
In addition, Bureau of immunization (BOI) field staff will be conducting kindergarten and seventh
grade validation surveys during the winter months. A survey protocol has been prepared and
randomly selected schools will be notified well in advance of this audit.
If you have any questions concerning this information, please contact your BOI field staff
representative (see Attachment 3), or Emily Fogarty at (850) 245-4342 or SUNCOM 205-4342,
extension 2395.
BJS/cha/eaf
Attachments
cc:
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Nancy Humbert, A.R.N.P., M.S.N.
Deputy Secretary for Health
Dr. Russell W. Eggert, M.D., M.P.H., Director
Division of Disease Control
Annette Phelps, A.R.N.P., M.S.N., Director
Division of Family Health Services
Charles H. Alexander, Chief
Bureau of Immunization
Bambi J. Lockman
Department of Education (without Attachment Form 685)
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County Health Department Nursing Directors
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Bureau of Immunization Field Staff
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Attachment
1
PUBLIC SCHOOL DISTRICTS (COUNTIES)
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ACCEPTED FOR ELECTRONIC REPORTING FOR KINDERGARTEN
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The 65 public school districts (counties) listed below have consistently achieved a
standard of less than five percent variance in their electronic data and manual reporting
for kindergarten during the years of dual reporting. Their electronic data is acceptable
and they are exempt from submitting Form 684 for public school kindergarten for th
school year 2006 - 2007
1
.
Alachua
Bay
Brevard
Calhoun
Citrus
Collier
Miami-Dade
Dixie
Escambia
Gilchrist
Gulf
Hardee
Hernando
Hillsborough
Indian River
Jefferson
Lake
Leon
Liberty
Manatee
Martin
Nassau
Okeechobee
Osceola
Pasco
Polk
St. Johns
Santa Rosa
Seminole
Suwannee
Union
Wakulla
Washington
Baker
Bradford
Broward
Charlotte
Clay
Columbia
DeSoto
Duval
Flagler
Glades
Hamilton
Hendry
Highlands
Holmes
Jackson
Lafayette
Lee
Levy
Madison
Marion
Monroe
Okaloosa
Orange
Palm
Beach
Pinellas
Putnam
St. Lucie
Sarasota
Sumter
Taylor
Volusia
Walton
1
Only two counties still required to file by paper form are Franklin and Gadsden.
A
ttachment
2
PUBLIC SCHOOL DISTRICTS (COUNTIES)
ACCEPTED FOR ELECTRONIC REPORTING FOR SEVENTH GRADE
The 65 public school districts (counties) listed below have consistently achieved a
standard of less than five percent variance in their electronic data and manual reporting
for seventh grade during the years of dual reporting. Their electronic data is acceptable
and they are exempt from submitting Form 684 for public school seventh grade for th
school year 2006 - 2007
2
.
Alachua
Bay
Brevard
Calhoun
Citrus
Collier
Miami-Dade
Dixie
Escambia
Gadsden
Glades
Hamilton
Hendry
Highlands
Holmes
Jackson
Lafayette
Lee
Levy
Madison
Marion
Monroe
Okaloosa
Orange
Palm Beach
Pinellas
Putnam
St. Lucie
Sarasota
Sumter
Taylor
Wakulla
Washington
Baker
Bradford
Broward
Charlotte
Clay
Columbia
Desoto
Duval
Flagler
Gilchrist
Gulf
Hardee
Hernando
Hillsborough
Indian
River
Jefferson
Lake
Leon
Liberty
Manatee
Martin
Nassau
Okeechobee
Osceola
Pasco
Polk
St.
Johns
Santa Rosa
Seminole
Suwannee
Volusia
Walton
2
Only two counties still required to file by paper form are Franklin and Union.
IMMUNIZATION ANNUAL REPORT OF COMPLIANCE FOR KINDERGARTEN AND SEVENTH GRADE
COMPULSORY IMMUNIZATION - FLORIDA STATUTES 1003.22
School Information
Date
Name
of
School:
School
Type:
Public
Nonpublic
Address:
City
County
Zip
Information on the person completing this form:
Name:
Position/Agency:
Name
of
Principal:
Phone
Number:
Student Information
List students not fully immunized – indicate type of exemption or out of compliance.
Name Grade
Medical Exemptions
Religious
Exemption
DH-681
30-Day
Transfer
Exemptions
List Enrollment
Date
Out of
Compliance
Temporary
DH-680
(Part B)*
List Expiration
Date
Permanent
DH-680
(Part C)
K
or 7
th
K
or 7
th
K
or 7
th
K
or 7
th
K
or 7
th
K
or 7
th
K
or 7
th
K
or 7
th
K
or 7
th
K
or 7
th
K
or 7
th
K
or 7
th
K
or 7
th
Summary Information
Provide the total number of students in each category.
Students
Enrolled in
Grade
Fully
Immunized
Have DH-680
(Part A-1 or A-2)
Medical Exemptions
Religious
Exemption
DH-681
30-Day
Transfer
Exemptions
Out of
Compliance
Temporary
DH-680
(Part B)*
Permanent
DH-680
(Part C)
Kindergarten
Seventh Grade
Submit by October 1, 2006 to: County Health Department
*Include only those students who have a current Temporary Medical Exemption as of the date on this form.
List students whose exemption expires before the date on this form as out of compliance.
DH Form 684, 01/2005 (Obsoletes all previous versions)
INSTRUCTIONS FOR COMPLETING FORM 684
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This form is to be completed by each public and private school, as required under Chapter 1003.22,
Florida Statutes. The original is to be completed and sent to the county health department by no later
than October 1. The copy should be retained at the school.
TO COMPLETE FORM:
A. School Information:
Fill in identifying information.
B. Student Information:
Check and/or complete the appropriate categories.
•
Student’s Name
•
Student’s Grade
•
Medical Exemptions:
- Temporary Medical Exemption: Children who have been enrolled after presenting
Form DH-680 Part B signed by a licensed physician or authorized designee. The
expiration date must be recorded and not be out of date.
- Permanent Medical Exemption: Children who have been enrolled after presenting
Form DH-680 Part C, signed by a licensed physician or authorized designee.
•
Religious Exemption:
- Children who have been enrolled after presenting Form DH-681, signed by the
parent or guardian.
•
30-Day Transfer Exemption:
- This exemption, issued by an authorized school official, applies to those children
transferring from outside the State of Florida or from one county to another.
•
Out of Compliance:
- Children who do not meet the immunization requirements set by law.
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For example,
a child who has an expired Temporary Medical Exemption, or a child who has been
enrolled in school for over 30 days without a DH-680, would be considered out of
compliance.
C. Summary Information:
Enter the total number of children in each category.
Any questions regarding this form or the requirements of the law should be addressed to the
local county health department.
KINDERGARTEN AND SEVENTH GRADE ANNUAL REPORT OF COMPLIANCE COUNTY SUMMARY
COMPULSORY IMMUNIZATION - FLORIDA STATUTES 1003.22
County
Date
Kindergarten
Total Number of:
Number of Students in Each Category:
Schools with
Kindergarten
Children
Enrolled
Fully
Immunized
Have DH-680
(Part A or A-1)
Medical Exemptions
Religious
Exemption
DH-681
30-Day
Transfer
Exemptions
Out of
Compliance
Temporary
DH-680
(Part B)
Permanent
DH-680
(Part C)
Public
Schools
Nonpublic
Schools
Total
Seventh Grade
Total Number of:
Number of Students in Each Category:
Schools with
Seventh
Grade
Children
Enrolled
Fully
Immunized
Have DH-680
(Part A or A-2)
Medical Exemptions
Religious
Exemption
DH-681
30-Day
Transfer
Exemptions
Out of
Compliance
Temporary
DH-680
(Part B)
Permanent
DH-680
(Part C)
Public
Schools
Nonpublic
Schools
Total
Send to:
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Bureau of Immunization
4052 Bald Cypress Way, Bin A-11
Tallahassee, Florida 32399-1719
Report
Submitted
by:
Name
Due Date: October 31, 2006
DH Form 685, 07/2005 (Obsoletes all previous versions)
BUREAU OF IMMUNIZATION FIELD STAFF
NORTH
Laura Kearns, Regional Manager
(850) 245-4444 Ext 2388
SOUTH
Rick Barrett, Regional Manager
(850) 245-4444 Ext 2392
HELEN MORES (Area 1)
Mailing
Bureau of Immunization
Escambia County Health Department
1295 W Fairfield Drive
Pensacola, FL 32501
Overnight Packages
Bureau of Immunization
Escambia County Health Department
8390 North Palafox St.
Pensacola, FL 32534
(850) 484-5191/
SC
690-5191
Cell
(850) 528-5135
Fax
(850) 484-5136/
SC
690-5136
Sr. Clerk: VACANT
(850) 484-5121/
SC
690-5121
Bay Escambia
Gulf
Holmes Jackson
Okaloosa
Santa Rosa
Walton
Washington
JO ANN WESTAWAY(Area 2)
Physical
Leon County Health Department
Bureau of Immunization
2965 Municipal Way
Tallahassee, FL 32304
Mailing
P.O. Box 2745
Tallahassee, FL 32316
(850) 487-3146 Ext 118/
SC
277-3146
Cell
(850) 528-5138
Fax
(850) 487-7954
Sr. Clerk: Candis Pesquera
(850) 487-3146 Ext 111/
SC
277-3146
Calhoun Columbia
Dixie
Franklin Gadsden
Gilchrist
Hamilton Jefferson
Lafayette
Leon Liberty
Madison
Suwannee Taylor
Wakulla
WANDA WEITMAN (Area 7)
Physical
1255 Brice Boulevard
Bartow, FL 33830
Mailing
Bureau of Immunization
1290 Golfview Ave., 4th Floor
Bartow, FL 33830-6740
(863) 519-7900, Ext 1226
SC
515-9668
Cell
(850) 528-5145
Fax
(863) 519-8307
Sr. Clerk: CaSandra McClain
(863) 519-7900, Ext 1227
SC
515-9668
Hardee Highlands
Okeechobee Osceola
Polk
LORI A. WRIGHT (Area 8)
Physical
Florida Dept. of Health-Bureau of
Immunization-Field Managers
4951B East Adamo Drive,
Suite 228, Room 115
Tampa, FL 33605
(813) 307-8015 Ext 2906 SC 582-2906
FAX: (813) 307-8088
Mailing
Hillsborough County Health Dept.
1105 E. Kennedy Drive
Tampa, Florida 33602
(813) 307-8015 Ext 2906
SC
582-2906
Cell
(850) 528-5137
Fax
(813) 307-8088
Sr. Clerk: Victoria Jones-Harris
Ext 2907
SC
582-2907
Hillsborough Manatee
SUZANNAH PUIGDOMENECH (Area 3)
Bureau of Immunization Field Staff
Duval County Health Department
MC-95
900 N. University Blvd.
Room 102
Jacksonville, FL 32211
(904) 665-2513/
SC
853-2513
Cell
(850) 528-5143
Fax
(904) 632-5350
Sr. Clerk: VACANT
(904) 665-2512/
SC
853-2512
Alachua Baker
Bradford Clay
Duval Nassau
St. Johns
Union
NITA ZAHRT (Area 4)
Mailing
Bureau of Immunization
Volusia County Health Department
P.O. Box 9190
Bin # 101
Daytona Beach, FL 32120-9190
Overnight/Certified Mail Address
1845 Holsonback Dr. Bin # 101
Daytona Beach, FL 32117-5114
(386) 274-0638/
SC
370-0638
Cell
(850) 528-5140
Fax
(386) 274-0637/
SC
370-0637
Sr. Clerk: VACANT
(386) 274-0636/
SC
370-0636
Flagler Levy
Marion Putnam
Volusia
DAVID FEE, M.Ed., C.H.E.S. (Area 9)
Bureau of Immunization
Ft. Myers Field Office
Regional Service Center
2295 Victoria Ave., Room 206
Ft. Myers, FL 33901-3866
(239) 461-6115
Cell
(850) 528-5136
Fax
(239) 461-6104
Sr. Clerk: Matthew Ellis
(239) 461-6116
Charlotte Collier
DeSoto Lee
Sarasota
ROBERT T. ANDERSON (Area 10)
Physical
Bureau of Immunization Field Office
A.G. Holley Hospital Complex
Bldg. 2, Room 201
1199 W. Lantana Rd.
Lantana, Florida 33462
Mailing
Bureau of Immunization Field Staff
A. G. Holley Hospital Complex
Building 2, Room 201
P.O. Box 3084
Lantana, FL 33465
(561) 540-1103/
SC
256-1103
Cell
(850) 528-5142
Fax
(561) 540-1106/
SC
256-1106
Sr. Clerk: Mary Cole
(561) 540-1102/
SC
256-1102
Indian River
Martin
Palm Beach
St. Lucie
ROBERT COLON (Area 5)
Department of Health
Bureau of Immunization
1111 N. Rock Springs Road
Apopka, FL 32712
(407) 654-1078
Cell
(850) 528-5144
Fax
(407) 654-1014
Sr. Clerk: Rosemary Roldan
(407) 654-1036
Brevard
Lake
Orange Seminole
CHARLES LONGBOAT (Area 6)
Florida Department of Health
Bureau of Immunization
4175 East Bay Drive, Suite 128A
Clearwater, Florida 33764
(727) 507-4427/
SC
517-4319
Cell
(850) 528-5134
Fax
(727) 507-4429/
SC
517-4321
Sr. Clerk: Mohammed Sardar
(727) 507-4428/
SC
517-4320
Citrus Hernando
Pasco Pinellas
Sumter
SAMHARA ESTRADA (Area 11)
Physical
Bureau of Immunization
Broward County Health Department
2421 S. W. 6th Ave.
Ft. Lauderdale, FL 33315
Mailing
780 SW 24th Street,
Ft. Lauderdale, Florida 33315
(954) 468-2718/
SC
453-2718
Cell
(850) 528-5141
Fax
(954)-847-3556
Sr. Clerk: Julia Paul-Mondaizie
(954) 468-2717/
SC
453-2717
Broward Hendry
Glades
MICHAEL T. MCCULLOM (Area 12)
Special Immunization Program
Corporate Park
C/O Michael McCullom
7769 N.W.48th Street Suite 350
Miami, FL 33166
(786) 845-0550 Ext 110
SC
429-0550 Ext 110
Cell
(850) 528-5139
Fax
(786) 845-0598
Sr. Clerk: Celia Rodriguez Del Rey
Ext 118
Dade Monroe
Cameron Noblit = Office:
(850) 245-4444 Ext.2393
Blackberry
: (850) 251-5575
Frank Roldan = Office:
(407) 654-1042
Blackberry:
(850) 519-1171
7/25/06
