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...
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