Contents
Form Example
Addendum to Td Vaccine (Tetanus and Diphtheria) Vaccine Information Statement
1.I agree that the person named below will get the vaccine checked below.
2.I received or was offered a copy of the Vaccine Information Statement (VIS) for the vaccine listed above.
3.I know the risks of the disease this vaccine prevents.
4.I know the benefits and risks of the vaccine.
5.I have had a chance to ask questions about the disease the vaccine prevents, the vaccine, and how the vaccine is given.
6.I know that the person named below will have the vaccine put in his/her body to prevent the disease this vaccine prevents.
7.I am an adult who can legally consent for the person named below to get the vaccine. I freely and voluntarily give my signed permission for this vaccine.
Vaccine to be given:
Tetanus and Diphtheria (Td)
Tetanus
Information about person to receive vaccine (Please print)
Name: Last |
First |
Middle Initial |
Birthdate |
Sex |
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(mm/dd/yy) |
(circle one) |
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M |
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F |
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Address: Street |
City |
County |
State |
Zip |
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TX
Signature of person to receive vaccine or person authorized to make the request (parent or guardian):
x |
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Date: |
x |
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Date: |
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Witness |
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PRIVACY NOTIFICATION - With few exceptions, you have the right to request and be informed about information that the State of Texas collects about you. You are entitled to receive and review the information upon request. You also have the right to ask the state agency to correct any information that is determined to be incorrect. See http://www.dshs.texas.gov for more information on Privacy Notification. (Reference: Government Code, Section 552.021, 552.023, 559.003, and 559.004)
Privacy Notice: I acknowledge that I have received a copy of my immunization provider’s HIPAA Privacy Notice.
For Clinic / Office Use Only
Clinic / Office Address:
Date Vaccine Administered:
Vaccine Manufacturer:
Vaccine Lot Number:
Site of Injection:
Title of Vaccine Administrator:
Signature of Vaccine Administrator:
Date VIS Given:
Notice: Alterations or changes to this publication is prohibited without the express written consent of the Texas Department of State Health Services, Immunization Unit.
Instructions: File this consent statement in the patient’s chart.
Immunization Unit |
CDC VIS Revision 04/11/2017 |
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Common mistakes
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Incomplete Information: Failing to fill in all required fields, such as the name, birthdate, or address of the person receiving the vaccine, can lead to delays or issues with vaccination records.
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Incorrect Signature: The signature must be from the person receiving the vaccine or an authorized individual, such as a parent or guardian. Using an unauthorized signature can invalidate the consent.
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Missing Date: Not including the date next to the signature can create confusion regarding when consent was given, potentially complicating the vaccination process.
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Failure to Circle Gender: Not circling 'M' or 'F' next to the sex field may result in incomplete documentation, which is essential for accurate medical records.
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Ignoring Privacy Notification: Overlooking the privacy notification section may prevent individuals from understanding their rights regarding personal health information.
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Not Reviewing the Vaccine Information Statement (VIS): Failing to acknowledge receipt of the VIS can lead to a lack of understanding of the vaccine's benefits and risks.
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Incorrect Vaccine Information: Providing incorrect details about the vaccine, such as the vaccine type or lot number, can result in complications with vaccination tracking and reporting.
Key takeaways
Filling out and using the Texas Addendum To Tdap Vaccine form requires attention to detail and understanding of its components. Here are key takeaways to consider:
- The form serves as a consent document for administering the Tetanus and Diphtheria (Td) vaccine.
- It is essential to provide accurate information about the person receiving the vaccine, including their name, birthdate, and address.
- The form includes a section for the signature of the individual receiving the vaccine or an authorized person, such as a parent or guardian.
- Before signing, individuals must acknowledge that they have received or were offered the Vaccine Information Statement (VIS).
- Understanding the risks of the disease and the vaccine is crucial before providing consent.
- Questions about the vaccine and its administration should be asked prior to signing the form.
- It is important to note that the signer must be an adult who can legally consent for the vaccine.
- The form requires the date of signature, which is necessary for record-keeping.
- Privacy notifications inform individuals of their rights regarding the information collected by the State of Texas.
- Healthcare providers must file the consent statement in the patient’s chart after completion.
Each of these points highlights the importance of careful completion and understanding of the Texas Addendum To Tdap Vaccine form to ensure proper vaccination procedures are followed.
Steps to Using Texas Addendum To Tdap Vaccine
Completing the Texas Addendum To Tdap Vaccine form is a straightforward process. After filling out the necessary information, the form needs to be signed and dated. This ensures that the individual receiving the vaccine or their authorized representative has consented to the vaccination.
- Begin by reading the entire form carefully to understand the requirements and information needed.
- In the section labeled "Vaccine to be given," clearly indicate "Tetanus and Diphtheria (Td)." This specifies the vaccine being administered.
- Locate the section titled "Information about person to receive vaccine." Print the following details:
- Name: Enter the last name, first name, and middle initial of the individual receiving the vaccine.
- Birthdate: Fill in the birthdate in the format mm/dd/yy.
- Sex: Circle either "M" for male or "F" for female.
- Address: Provide the complete street address, city, county, state (TX), and zip code.
- Next, find the section for the signature. The person receiving the vaccine or an authorized individual (such as a parent or guardian) must sign their name.
- Below the signature, enter the date of signing.
- In the witness section, a witness must also sign and date the form.
After completing these steps, ensure that the form is submitted to the appropriate clinic or healthcare provider for processing. The provider will handle the remaining documentation related to the vaccination.