Ecers Score Sheet – Fill Out and Use This PDF

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.

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

552.021, 552.023, 559.003, and 559.004)

PrivacyNotice:IacknowledgethatIhavereceivedacopyofmyimmunizationprovider'sHIPAAPrivacyNotice.

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.