DJJ Form HS022 "Parental Notification of Health-Related Care: Vaccination/Immunization" - Florida

What Is DJJ Form HS022?

This is a legal form that was released by the Florida Department of Juvenile Justice - a government authority operating within Florida. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on February 1, 2010;
  • The latest edition provided by the Florida Department of Juvenile Justice;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of DJJ Form HS022 by clicking the link below or browse more documents and templates provided by the Florida Department of Juvenile Justice.

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Download DJJ Form HS022 "Parental Notification of Health-Related Care: Vaccination/Immunization" - Florida

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FLORIDA DEPARTMENT OF JUVENILE JUSTICE
PARENTAL NOTIFICATION OF HEALTH-RELATED CARE:
VACCINATION/IMMUNIZATION
N
Y
: ____________________________________ D
B
: ___________
AME OF
OUTH
ATE OF
IRTH
F
N
: ______________________________ DJJID#: __________ D
: __________
ACILITY
AME
ATE
P
/
:
ARENT
GUARDIAN NAME AND ADDRESS
DJJ F
:
ACILITY NAME AND ADDRESS
Dear
:
Our records indicate that you are the parent or guardian who has authority over health care for the above
named youth. The purpose of this form is to notify you that the following vaccination(s) has/have been
ordered for your child. We have included a Vaccine Information Sheet known as a “VIS” that explains the
vaccination(s).
Name of Vaccination/VIS: ______________________________________________________
Publication Date of VIS: ________________________________________________________
If you have any further questions about this vaccination, please notify the DJJ facility at the phone
number indicated.
Phone number:
____________________________
_
____
Person to Contact:
___________________________
In order for us to provide this vaccination, we need your written permission. Please sign your name and
date your signature in the space provided and send this form back to us at the address listed above.
 I consent
 I do not consent
_____________________________________________
________________________________
Parent/Guardian Signature
Date Signed
Name of person at facility who completed this form___________________________
Staff: Prior to mailing, list the name of the VIS included with this notification, and
the date of the publication of the VIS (located in the lower right hand corner of the VIS).
** Copy of Notification to be filed in Individual Health Care Record.
Save As
Reset/Clear Form
Print Form
022
FORM
P
1
1
AGE
OF
63M-2
. 2/2010
REV
FLORIDA DEPARTMENT OF JUVENILE JUSTICE
PARENTAL NOTIFICATION OF HEALTH-RELATED CARE:
VACCINATION/IMMUNIZATION
N
Y
: ____________________________________ D
B
: ___________
AME OF
OUTH
ATE OF
IRTH
F
N
: ______________________________ DJJID#: __________ D
: __________
ACILITY
AME
ATE
P
/
:
ARENT
GUARDIAN NAME AND ADDRESS
DJJ F
:
ACILITY NAME AND ADDRESS
Dear
:
Our records indicate that you are the parent or guardian who has authority over health care for the above
named youth. The purpose of this form is to notify you that the following vaccination(s) has/have been
ordered for your child. We have included a Vaccine Information Sheet known as a “VIS” that explains the
vaccination(s).
Name of Vaccination/VIS: ______________________________________________________
Publication Date of VIS: ________________________________________________________
If you have any further questions about this vaccination, please notify the DJJ facility at the phone
number indicated.
Phone number:
____________________________
_
____
Person to Contact:
___________________________
In order for us to provide this vaccination, we need your written permission. Please sign your name and
date your signature in the space provided and send this form back to us at the address listed above.
 I consent
 I do not consent
_____________________________________________
________________________________
Parent/Guardian Signature
Date Signed
Name of person at facility who completed this form___________________________
Staff: Prior to mailing, list the name of the VIS included with this notification, and
the date of the publication of the VIS (located in the lower right hand corner of the VIS).
** Copy of Notification to be filed in Individual Health Care Record.
Save As
Reset/Clear Form
Print Form
022
FORM
P
1
1
AGE
OF
63M-2
. 2/2010
REV