EFTA01245697.pdf

FLORIDA CERTIFICATE OF IMMUNIZATION (HRS 680 - PART A) (ROSH Statures 232.032) •••••NIS FOR CHILDREN WHO HAVE COMPLETED ALL REQUIRED IMMUNIZATIONS FOR SCHOOL ATTENDANCE •444.14., OF BIRTH CHLOS RAMS CA PARENT OR GLIARDAN DOCTOR: PART A OF RES FOAM IS USED OMIT IF TAE CHILD HAS RECEIVED All iECUIDE3 IMIUNIZATIOM LISTED 6fLOW. IF MT SEE PDIRSE SEE. a DTP — 5 POSES DECLARED IF THE FOURTH PRIMARY DOSE OF VIP IS ADM MSTERED CR OR'AFTER DETOINTRENTODATI:A.BFTHOOSEISNOT REOUIPEO. DT (PEI:PIRO) VACCINE IS ACCEPTABLE F PERTUSSIS VACCNE 15, 4BICALLY plyittiotrAtecticomptElt PART DEOPTEERTUSSIS CONTRANOICARON) Td (ADULT) VACCINE (A SERES OF 3 00SES) G ACCUTABLEANGRECONAtINEO'FOR;OUREN 7 YEARS OF AGE OR.OLDEk. POLIO ITEM) - 4 OASES IIKPARED IF NE THIRD NIPPY DOSE OF WV IS ADMINISTERED ON OR AFTER THE FOUFITHEIRTHDAY:APORTH DOWNS)! REOUIREO. POLIO VACCINE IS OMITTED FROM TIE REONE:614MUIPPICINEOF CRLDREN 18 YEARS OF t °RODEN . • • • • KNEEL MLINPS. OD MHO - I RISE REGGIFO . • MMR COMBINED - 1DOSE AT 12 /A0I111-6 OF AGE ORULDEFFAININ offutopootempao..ATlooms) MEASLES SINGLE - 1DOSE AT 12 MONTHS OF AGE OR OLOER AND DIVED 0DLATEDI(II DOIDARIDDONt lEMONINS) MO OA YR • . MUMPS SINGLE - 1 DOSE AT 12 WNW Of AGEOR MOEN MO DA YR RUBELLA SINGLE - 1DOSE AT 12 MONTHS OF AGE OR OLDER AP DA YR ALL APPROPRIATE DOSES AND DATES INCLUDING BETHDATE MUST BE ENTERED, AND THE CERTIFICATE SIGNED BELOW BY A PHYSICIAN CR AUTHORIZED PERSON AND DATED IN ORDER FOR THE CHILD TO ATTEND SCHOOL A LIMO, M.D. I HAVE RENEWED THE RECOR T OF MY KRONA-EDGE THE ABOVE NAMED CHILD HAS BEEN ADEQUATELY IMMUNIZED AGAINST DIPHTHERIA, TEWIUS,PERTU RUBELLA AS REQUIRED BY FLORIDA LAW FOR SCHOOL ATTENDANCE. PHYSICIAN OR MINK NAME (PLEASE PRINT) PHYSICIAN OR AUTHORIZED SIGNATURE DATE MMO8e00030 3501.055-050 Page 1 of 2 CONFIDENTIAL EFTA_00058098 EFTA01245697 I . DATE CF SRN I I CHILDS NAME MO DA YR PARENT OR GUARDIAN DOCTOR: IF THE CHILD HAS NOT RECEIVED THE R EOUIRED DOSES LISTED IN PART A, PLEASE COMPLETE PART El OR PART C, AS APPROPRIATE, AND SIGN AND DATE. TEMPORARY MEDICAL EXEMPTION (HRS 680 -,PART B) FOR PRESCHOOL CHILDREN AND FOR SCHOOL CHILDREN WITHOUT ALL IMMUNIZATIONS REQUIRED IN PART A I CERTIFY THAT THE ABOVE NAMED CHLD HAS RECEIVED THE IMMUNIZATIONS LISTED BELOW AND HAS COMMENCED A SCHEDULE TO COMPLETE THE REQUIRED IMMUNIZATIONS. ADDITIONAL IMMUNIZATIONS ARE NOT MEDICALLY INDICATED AT THIS TIME. TYPE VACCNE . DATE (MO/DA/YR) DATE IMO/DA/YIN DATE (IAWITALYIT) DATE (MO/DA/YR) DATE IMO/DA/YR) DTP 07 To KU() Hi) ISAR RUBECLA (MEASLES) EMMA OTTE (MO/DA/YR) MUMPS (SHOULD BE 15 DAYS AFTER NEXT AP, ONTMENT) RUBELLA PHYSICIAN OR AUTHORIZED SKIIVOURE DATE PERMANENT MEDICAL EXEMPTION (HRS 680 - PART C) I CERTIFY THAT THE PHYSICAL CONDITION OF 1MS CHILD IS SUCH THAT IMMUNIZATIONS) IS MEDICALLY CONTRAINDICATED. LIST VACCINE(S) AND STATE VALID CLINICAL REASONING OR EVIDENCE FOR EkEMPTION FOR EACH VACCINE. PRYSILIAMS SONATURE DATE HAS Foresee:b....et SI lOberietes proms aim's) (Stock Number 5740.00030680-S; mmo8-e00031 3501.055-050 Page 2 of 2 CONFIDENTIAL EFTA_00058099 EFTA01245698