DICALLY CONTRAINDICATED. LIST VACCINE(S) AND STATE VALID PHYSICIAN OR CLINIC NAME (PLEASE PRINT) PHYSICIAN'S SIGNATURE DATE HRS Form 680. JAN 93 (Repbces Mat 91 edition which may be ized) (Stock Number 5740-000.0680-6) DOE AUTOMATED STUDENT DATA BASE CODES: ' IMMUNIZATION STATUS CODE / ' VACCINATION COD