Ecers Score Sheet PDF Details

The Ecers Score Sheet form, created by the Texas Department of State Health Services, serves as a vital document within the domain of public health, specifically focusing on the administration of vaccines. It outlines a structured process whereby an individual or a guardian provides informed consent for vaccination, clearly detailing several key elements. These components include acknowledgment of having received or been offered the Vaccine Information Statement (VIS), understanding the risks associated with the disease the vaccine aims to prevent, comprehending the benefits and potential risks of the vaccine itself, and the opportunity to inquire further about the disease, the vaccine, and the vaccination process. Furthermore, it confirms the respondent’s legal capability to consent for the patient mentioned in the document to receive the specified vaccine, in this case, the Hepatitis B vaccine. Essential patient information is captured, including name, birthdate, sex, and address, alongside the signature of the person giving consent and the date. The form also provides space for crucial administrative details such as the clinic or office address, the date the vaccine was administered, the vaccine manufacturer, lot number, the site of administration, and the signature and title of the vaccine administrator. Importantly, the form includes a privacy notification segment, emphasizing the rights of individuals regarding their personal information according to the State of Texas, and underscores the importance of storing this consent form in the patient's chart, ensuring compliance with state regulations and reinforcing the document's significance in vaccination documentation and patient health records management.

Form NameEcers Score Sheet
Form Length1 pages
Fillable fields0
Avg. time to fill out15 sec
Other namesecers sheet, score ecers sheet, ecers score sheet printable, ecers score sheet

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Texas Department of State Health Services

Addendum to Hepatitis B 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


Middle Initial




(circle one)

























Address: Street







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

x __________________________________________________________ Date ____________

__________________________________________________________ Date ____________


For Clinic/Office Use

Clinic/Office Address:

Date Vaccine Administered:

Vaccine Manufacturer:

Vaccine Lot Number:

Site of Administration:

Signature of Vaccine Administrator:

Title of Vaccine Administrator:

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 for more information on Privacy Notification. (Reference: Government Code, Section

552.021, 552.023, 559.003, and 559.004)


Notice: Alterations or changes to this publication is prohibited without the express written consent of the Texas Department of State Health Services, Immunization Branch.

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

Texas Department of State Health Services EC-106(07/07)

CDC VIS Interim Revision 07/18/07

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