Ecers Score Sheet PDF Details

The Ecers score sheet is an assessment tool that is used to measure a child’s development in the areas of education, cognition, and social emotional development. The score sheet can be used to help identify any developmental concerns that may need further evaluation. The score sheet assesses a child’s abilities in five main domains: physical well-being and motor skills, personal/social responsibility, language and communication, cognitive skills, and mathematical reasoning. Each domain is assessed on a scale of one to four, with one being the lowest level of development and four being the highest. A total score is also calculated for each domain and the overall composite score.

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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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ecers 3 score sheet fields to fill out

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