for Kindergarten and Seventh Compulsory Immunization—Section 1003.22, Florida Statutes (A) Private School Information: Date: __________ Name of School: Information on the person completing this form: Address: Name: City Zip County Position/Agency: Name of Principal: Number: (B) Student Information: List only those students who are not fully immunized for grade. Indicate exemption type or if out of compliance. Exemptions expiring before October 1 of the current year are out of compliance. 30-Day Medical Exemptions Religious Transfer Temporary Out of Grade Exemptions Exemption Student Name Permanent (Part B) Compliance (DH 681) (Part C) List Expiration List Enrollment Date (Last, First) Date K or 7th K or 7th K or 7th K or 7th K or 7th K or 7th K or 7th K or 7th K or 7th K or 7th (C) Summary Information: Provide the total number of students in each category. Fully Medical Exemptions Religious 30-Day Students Out of Immunized Temporary Permanent Exemption Transfer Enrolled DH 680 Compliance DH 680 DH 680 Grade (DH 681) Exemptions (Part A) (Part B) (Part C) Kindergarten Seventh Submit to the following local county health department by October 1: DH Form 684, 07/17
for Kindergarten and Seventh Compulsory Immunization—Section 1003.22, Florida Statutes (A) Private School Information: Date: __________ Name of School: Address: Information on the person completing this form: Name: City Zip County Position/Agency: Name of Principal: Number: (B) Student Information: List only those students who are not fully immunized for grade. Indicate exemption type or if out of compliance. Exemptions expiring before October 1 of the current year are out of compliance. Student Name (Last, First) Grade Medical Exemptions Religious Exemption (DH 681) 30-Day Transfer Exemptions List Enrollment Date Out of Compliance Temporary (Part B) List Expiration Date Permanent (Part C) K or 7th K or 7th K or 7th K or 7th K or 7th K or 7th K or 7th K or 7th K or 7th K or 7th (C) Summary Information: Provide the total number of students in each category. Grade Students Enrolled Fully Immunized DH 680 (Part A) 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 Submit to the following local county health department by October 1: DH Form 684, 07/17