Ec 106 Form PDF Details

Vaccinations are a critical component of public health, providing protection against various diseases, with the Hepatitis B vaccine being one of them. The EC 106 form plays a vital role in this process as it serves as an addendum to the Hepatitis B Vaccine Information Statement (VIS), ensuring that individuals receiving this vaccine or their guardians are fully informed and consent to the vaccination. This document outlines key elements, such as the acknowledgment of receiving or being offered the VIS, understanding the risks associated with the disease and the vaccine, and the opportunity to ask questions about the vaccination process. Additionally, it details how the vaccine will be administered, confirms the legal consent of the adult responsible for the recipient, and collects essential information like the recipient's name, birthdate, and address. A signature from the recipient or the authorized guardian is required to validate the consent. Furthermore, the form emphasizes privacy rights, indicating that recipients are entitled to know how their information is used and have the right to request corrections on incorrect data. The EC 106 form also includes space for documenting the vaccine's administration details, such as the date, manufacturer, lot number, and the administrator's title and signature, ensuring a comprehensive record is kept within the patient's chart. This addendum not only supports transparency and informed consent but also adheres to privacy laws and regulations, highlighting the significance of patient rights and the responsibilities of immunization providers.

QuestionAnswer
Form NameEc 106 Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namestexas dshs hepatitis b, tdap consent form, addendum hepatitis b, tdap dtap for adults

Form Preview Example

Addendum to Hepatitis B Vaccine:

What You Need to Know

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:

Hepatitis B Vaccine

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Information about person to receive vaccine (Please print)

 

 

 

 

 

 

 

 

 

 

Name: Last

First

Middle Initial

Birthdate

 

Sex

 

 

 

 

 

 

 

(mm/dd/yy)

(circle one)

 

 

 

 

 

 

 

 

 

 

M

 

F

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address: Street

 

City

 

County

 

State

 

Zip

 

 

 

 

 

 

 

 

 

 

TX

 

 

 

 

Signature of person to receive vaccine or person authorized to make the request (parent or guardian):

 

 

 

 

x

 

 

 

 

 

 

Date:

 

 

 

 

x

 

 

 

 

 

 

 

Date:

 

 

 

 

 

 

Witness

 

 

 

 

 

 

 

 

 

 

 

 

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.

Instructions: File this consent statement in the patient’s chart.

Immunizations

CDC VIS Revision 10/15/2021

C-106 (10/21)

 

How to Edit Ec 106 Form Online for Free

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part 1 to completing tdap documentation

In the Clinic Office Address, For Clinic Office Use Only, Date Vaccine Administered Vaccine, Notice Alterations or changes to, Instructions File this consent, Immunizations C, and CDC VIS Revision box, write down the information you have.

Entering details in tdap documentation part 2

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