FLORIDA CERTIFICATION OF IMMUNIZATION Legal Authority: sections 232.03Z, 402.305, 402.313, Florida Statutes; rules 640-3.011, 65C-22.006, 65C-20.011, Florida Administrative Code LAST N FIRST NAME MI DOB (MO/DA/YR) PARENT OR GUARDIAN CHILD'S SS# (optional) STATE IMMUNIZATION IMP Directions: Enter all appropriate doses and dates below. Sign and date appropriate certificate (A-1, A-2, B, or C) on reverse side of form. If the child is presenting for the 7 th grade requirement only and has previously filed a Certificate of Immunization (DR 680, Part A-1) with their current Florida school, fill in boxed areas below and complete Part A-2 on the reverse side of this form. For additional information: See Immunization Guidelines for School and Child Care Facilities for information and instructions on form completion and immunization requirements. Guidelines are available from the local county health department. DOE Dose 1 VACCINE CODE %4 all‘h DTaP/DTP2 A Teti Polio' Hill MMR (Combined)' F. (Separate)° G,H,I Hepatitis B9 Varicella" Varicella Disease L Year Dose 2 Dose 3 ta III Lit II • Al . A P Dose 4 Dose 5 .a • lb . SAP • . • I The state immunization ID# is an identifier supplied by the state immunization registry (optional). 2 DTP/DTaP 5 doses required. If the 46 primary dose is administered on or after the 46 birthday a 56 dose is not required. 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 3" dose in an all OPV or all IPV series is administered on or after the 4" birthday, a 48, dose is not required. Polio vaccine is not required for children 18 years of age or older. 6 Hib is required for child care, family day care and preschool entry and attendance only. 7 First dose valid if given on or after 1" birthday. Second dose (m