Texas Addendum To Tdap Vaccine Form PDF Details

In an era marked by heightened awareness of public health and vaccination, the Texas Addendum to Tdap Vaccine form plays a critical role in documenting consent and understanding regarding the Tetanus and Diphtheria (Td) vaccination. At its core, this document serves as an agreement between the individual receiving the vaccine (or their guardian) and the administering health professional. It outlines several key elements essential for informed consent: acknowledgment of receipt or the offer to receive the Vaccine Information Statement (VIS), understanding of the risks associated with both the disease and the vaccine, the opportunity to ask questions, and a declaration of the recipient's legal capacity to consent. Additionally, it captures vital information about the recipient, including their name, birthdate, and contact details, alongside the signature of the individual or guardian providing consent. The form also emphasizes privacy rights under Texas law, informing recipients of their entitlement to access and correct personal information held by the state, and includes a spot for acknowledging receipt of the immunization provider’s HIPAA Privacy Notice. For healthcare providers, the document details logistical aspects of the vaccination process, such as the date administered, vaccine manufacturer, lot number, and injection site, thus ensuring a comprehensive record for clinical use. Notably, the form underscores the importance of formal documentation in vaccination procedures, reinforcing the ethical and legal frameworks that protect individuals' health and privacy rights. It embodies a crucial piece of the public health puzzle, facilitating a transparent and informed vaccine administration process, as mandated by the Texas Department of State Health Services.

QuestionAnswer
Form Name Texas Addendum To Tdap Vaccine Form
Form Length 1 pages
Fillable? No
Fillable fields 0
Avg. time to fill out 15 sec
Other names yy, Tdap, Texas, tdap texas department of state health conset form, ths c-94 form

Form Preview 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

 

 

 

 

(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 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

C-94 (07/17)

 

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Simple tips to complete tdap texas department of state health conset form part 1

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