DH Form 684, 06/2007 (Obsoletes all previous versions)

 

 

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

Information on the person completing this form:

Address:

Name:

City

County

Zip

Position/Agency:

       

Name of Principal:

       

Phone Number:

       

Student Information

List students not fully immunized – indicate type of exemption or out of compliance.

Medical Exemptions

Name Grade

Temporary

DH-680

(Part B)*

List Expiration

Date

Permanent

DH-680

(Part C)

Religious

Exemption

DH-681

30-Day

Transfer

Exemptions

 

List Enrollment

Date

Out of

Compliance

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.

Medical Exemptions

  

Students

Enrolled in

Grade

Fully

Immunized

Have DH-680

(Part A) or (DOE

Code C, 8 or 1)

Temporary

DH-680

(Part B)*

Permanent

DH-680

(Part C)

Religious

Exemption

DH-681

30-Day

Transfer

Exemptions

Out of

Compliance

Kindergarten

       

       

       

       

       

       

       

Seventh Grade

       

       

       

       

       

       

       

 

Submit by October 1, 2007 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.

---

 

 

 

INSTRUCTIONS FOR COMPLETING FORM 684

 

 

 

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. 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.