EFTA01710450.pdf

LAST NAME FIRST MI DOB (MO/DA/YR) Certificate of Immunization for K-12 Excluding 7th Grade Requirements PART A-1 (Immunizations are complete for school entry and attendance grades kindergarten through 12 with the exception of the 7th grade requirement) DOE Code 1 I have reviewed the records available, and to the best of my knowledge, the above named child has been adequately immunized against diphtheria, tetanus, patussis, polio, measles, mumps, rubella and hepatitis B (for kindergarten effective with the 1998/99 school year) for school attendance as documented on the reverie side of thisform. Physician or Clinic Name: Physician or (Pant or stamp) Authorized Signature: Address: Date: Certificate of Immunization Supplement for 7th Grade Requirement PART A-2 (Immunizations are complete for students who enter or attend the 7th grade after the beginning of the 1997/98 school year. Each subsequent year thereafter, the next highest grade will be included in the requirement) DOE Code 8 I have reviewed the records available, and to the best of my knowledge, the above named child has received the following immunizations requiredfor any and attendance in 7th grade effective with the 1997/98 school year: tetanus-diphtheria booster, hepatitis B vaccine series, and second dose of measles vaccine as documented on the reverse side of thisform (boxed areal). Physician or Clink Name: Physician or (Print or'stamp) Authorized Signature: Add Royal Palm Date: rfrAl Temporary Medical Exemption PART B (For preschool children, children in day care and school children who are incomplete for immunizations in Part A-1 or A-2.) Invalid without expiration date. DOE Code 2 I certify that the above named child has received the immunizations documented on the reverse side of thisform and has commenced a schedule to complete the required immunization. Additional immunizations are not medically indicated at this time. 14 ,.- Physician or Clinic Name: .-;.pmnrsitio iWn vate*s (Print or stamp) it Physician or Address: Authorized Signature: Date: Permanent Medical Exemption PART C For medically contraindicated immunizations, list each vaccine and state valid clinical reasoning or evidence for exemption: DOE Code 3 I certify that the physical condition of this child Is such that immunization(s) as indicated in Part C above is medically contraindicated. Physician or Clinic Name: (Print or stamp) Physician Signature: Address: Date: DH 610, 11/96. absoletet miler oditiccs (Stodc Numb": 5740000068%5) EFTA01710450  FLORIDA CERTIFICATION OF IMMUNIZATION Legal Authority: FLORIDA STATUTES 232.032, s. 10D-3.088, F.A.C. and s. 10M-12, F.A.C. LAST NAME FIRST MI DOB monmmt PARENT OR GUARDIAN Child's SS# (optional) STATE IMMUNIZATION IT#0 Directions: • Enter all appropriate doses and dates below. • Sign and date appropriate certificate (A-I, A-2, B, or C) on reverse side of form. • If the child is presenting for the 7th grade requirement :dij_il and has:previously filed a Certificate of Immunization (680A or 680A-1) with their current Florida school; fill in boxed areas below aniftkuplete Part A-2 on the reverse side of this form. -.--ct• ---- • -C'• f N ----• • For additional information: See munization: •in delines or choo and:Ch?idtire Facilities for information and instructions on fonn completicandlinginitip4tion:ratistertlent.S.:Guldepirtek,Ire updated annually and are available from the local county health departnifit...t.-.:: ' f •!' • •:'.`%:‘: ' ”..........:.... - .1 De, r e . • ...- •.. 1‘ VACCINE DOW .3- i'll:.._-:_46‘0 .. _ w... A _. 7.::/...? _ , OA"; __ :-.:, -.:..:111.fr.t ."?.` tboSc 4 Dose 5 CODt , 'll, Meinj.1,F,:;;SP1W . ,2.7. ..,..,. ( v.-gril:WD ..... -_-4 ..•=4 . A/YR MODA/YR DTaP/DTP2 ilk % 'if •:•5::; • .. • -.- ..-.1 ::: • .....ri -r,'" .. • . • •• • , .1,, v• v--..;:- • •\,.; .:•••••••••.. -• --.. - .., • ....,,r •-",- ..., • . .1, 7,-zzik -•••'; ' • ‘ • : :•',.• • 41 tv .--i:•/....4 . • .'N - 01. --, 'c' 1 ...," • '.:!`isa'n'l l•ti'l: ...' •l i - - -- -.: • . 1 Tds c..-....; v 1-,:t......., , C'thit ii, tyta-?vat,..L 7 f. . 0.:-.,--,... - it• 9-. ;2, 1 c..4‘1. C'. .!4%..71C4rE _,_' c-: Folios' ...1 . t . • •.-. •'• *• ! :11; •• st --- • '‘z - .N,: 1 . . ....') t. a: :7•74:.z(::Ci.:: - c itA ' I r.-........ .... • Itr 24: .??!......... r. .....J. • ‘.;.': -;, .. .%. - t.l.. ;;.,:: ‘1; ; 1) 2 : ( ' 'IN RiB6 •'...7• • •c, c v • hUVIR (Combined)? i 1. :" . ::,1.;:. r. • I ,.1 e.c.it::. V ... ........75.7 ". ' ' ...... XX , . •-.. ;,' -•',<::::•• ••• -•,•- y•:, (Separate)* G, H,\ki • ::1-. It, f.:••:e 4)2 '6,,.. • 7,'" ..: . i. :21' • e.• •• Hepatitis B9 The state immunization ID# is anidentifier 3Ippliedybyithe statelmaninizi tioirregistry (optional). 2 DI? 5 doses required. If the fourth primary dose filaiiiinistered:citirorafter the fourth birthday a fifth dose is not required. DTaP is an acceptable alternative for one or more doses of DTP. 3 DT (pediatric) is acceptable if Pertussis vaccine is medically contraindicated. (Complete Part C for Pertussis contraindication.) 4 Td (Adult) Vaccine is recommended for children 7 years of age or older. 5 Polio 4 doses required. If the third dose is administered on or after the fourth birthday, a fourth dose is not required. IPV is an acceptable alternative for one or more doses of OPV. Polio vaccine is not required for children 18 years of age or older. 6 Hib is required for child care and preschool entry and attendance only. 7 1st dose valid if given on or after 1st birthday. Second dose (measles) valid if given at least 1 month.after 1st dose. A second dose of measles (preferably MMR) is required for students in grades K-4 in the 1997-98 school year, and 7th grade entry and attendance effective with the 1997/98 school year. In each subsequent year thereafter, the, next highest grades are included. Includes single measles vaccine (G), single mumps vaccine (H) or single rubella vaccine (I). 9 Hepatitis B vaccine series is required for seventh grade entry and attendance effective with the 1997-98 school year and kindergarten entry and attendance effective with the 1998-99 school year. In each subsequent year thereafter, the next highest grades are included. EFTA01710451  LAST NAME FIRST MI DOB (MO/DANR) Certificate of Immunization for K-12 Excluding 7th Grade Requirements PART A-1 (Inununizations are complete for school entry and attendance grades kindergarten through 12 with the exception of the 7th grade requirement.) DOE Code 1 I have reviewed the records available, and to the best of my knowledge, the above named child has been adequately immunized against diphtheria, tetanus, pertussis, polio, measles, mumps, rubella and hepatitis B Or kindergarten effective with the 1998/99 school year) for school attendance as documented on the reverse side of thisform. Physician or Clinic Name: Physician or (Print or stamp) Authorized Signature: Address: Date: Certificate of Immunization Supplement for 7th Grade Requirement PART A-2 (Immunizations arc complete for students who enter or attend the 7th grade after the beginning of the 1997/98 school year. Each subsequent year thereafter, the next highest grade will be included in the requirement.) DOE Code 8 1 have reviewed the records available, and. to the best of my knowledge. the above named child has received the following immunizations requiredfor entry and attendance in 7th grade effective with the 1997/98 school year: tetanus-diphtheria booster, hepatitis B vaccine series, and second dose ofmeasles vaccine as documented on the reverse side of thisform (boxed arras). Physician or Clinic Name: Physician or (Print or stamp) Authorized Signature: Address: Date: Temporary Medical Exemption PART B (For preschool children, children in day care and school children who are incomplete for immunizations in Part A-I or A-2.) Invalid without expiration date. DOE Code 2 1certify that the above named child has received the immunizations documented on the reverse side of thisform and has commenced a schedule to complete the required immunizations. Additional immunizations are not medically indicated at this time. Physician or Clinic Name: Expiration Date: (Print or stamp) (15 dawn after nert InynardzstIon sp Physician or Address: Authorized Signature: Date: Permanent Medical Exemption PART C For medically contraindicated immunizations, list each vaccine and state valid clinical reasoning or evidence for exemption: DOE Code 3 1certify that the physical condition of this child is such that immunization(s) as indicated in Part C above is medically contraindicated. Physician or Clinic Name: (Print or stamp) Physician Signature: Address: Date: MI 640, 11/96, cttcolctes radio' editions (Stock Nanba. 5740000-0680-6) EFTA01710452