Vaccine Documentation Form PDF Details

In today’s health-conscious society, the Vaccine Documentation Form plays a pivotal role in ensuring that individuals are well informed about the vaccinations they or their dependents are receiving. This comprehensive form not only provides a detailed record of the vaccines administered but also ensures that recipients are fully aware of the Vaccine Information Statement (VIS) for each vaccine, understanding both the benefits and the potential risks associated with them. By requiring a signature, it confirms that the individual or guardian has been offered ample opportunity to ask questions regarding the diseases the vaccines aim to prevent, the vaccines themselves, and the vaccination process. Additionally, the form highlights the importance of legal consent from adults authorized to make medical decisions for the recipient, solidifying the agreement to proceed with vaccination in a committed and informed manner. Privacy concerns are also addressed, giving recipients the right to access and amend personal information, underscoring the form's alignment with HIPAA regulations and state laws concerning privacy and information sharing. With sections to document the date of administration, manufacturer details, lot numbers, and the healthcare provider's signature, it serves as an essential record for both medical professionals and patients, ensuring transparency and traceability of vaccine administration.

QuestionAnswer
Form NameVaccine Documentation Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesvaccine documentation form, vaccine documentation form blank, tx c 100, vaccine documentation form printable

Form Preview Example

Vaccine Documentation Form

(800)252-9152

I received or was offered a copy of the Vaccine Information

Statement (VIS) for each vaccine. I know the risks of the disease each vaccine prevents. I know the benefits and risks of

each vaccine. I have had a chance to ask questions about the disease, the vaccines, and how the vaccines are given. I know that the person receiving the vaccine will have the vaccine put into his/her body to prevent an infectious disease. I am an adult who can legally consent for the person named below to get the vaccine. I freely and voluntarily give my signed permis- sion for the vaccines.

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.tx.gov for more infor- mation 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.

Yes, HIPAA received

No HIPAA received

Recibí o se me ofreció una hoja con información sobre cada vacuna (VIS). Conozco los riesgos de las enfermedades que cada vacuna previene. Conozco los beneficios y riesgos que estas vacunas tienen. He tenido la oportunidad de hacer pre-

guntas sobre las enfermedades, las vacunas y cómo son admin- istradas las vacunas. Sé que la persona recibiendo la vacuna la tendrá en su cuerpo para prevenir una enfermedad contagiosa. Soy adulto y puedo dar permiso legalmente para que le den la

vacuna a la persona nombrada abajo. Por mi propia voluntad firmo y doy permiso para que le den esta vacuna.

Notificación Sobre Privacidad: Tan solo por unas cuantas excepciones, usted tiene el derecho de solicitar y de ser in- formado sobre la información que el Estado de Texas reúne sobre usted. A usted se le debe conceder el derecho de recibir y revisar la información al requerirla. Usted también tiene

el derecho de pedir que la agencia estatal corrija cualquier información que se ha determinado sea incorrecta. Diríjase

a http://www.dshs.tx.gov para más información sobre la Notificación sobre privacidad. (Referencia: Government Code, Sección 552.021, 552.023, 559.003 y 559.004)

Aviso sobre derechos de la vida privada: Yo admito haber recibido una copia del aviso sobre derechos de la vida privada.

Hepatitis B

DTaP/DT/DTP/Td/Tdap

Haemophilus influenzae type b(Hib)

Pneumococcal Conjugate (PCV)

Polio (IPV/OPV) (Circle one)

Rotavirus (RV)

Measles, Mumps, and Rubella (MMR)

Measles

Varicella (Chickenpox)

Meningococcal (MCV4/MPSV4)

Hepatitis A

Human Papillomavirus (HPV)

Pneumococcal Polysaccharide (PPSV)

Serogroup B Meningococcal (MenB)

Influenza

Si, Recibí HIPAA

No Recibí HIPAA

Check vaccines to be given then enter date, sign, and complete the section below.

Señale las vacunas que se van a dar, escriba la fecha, firme y llene la parte de abajo.

Date

Signature/Relation/Address/Telephone

Fecha

Firma/Relación/Dirección/Teléfono

Witness Signature/Firma del Testigo

Witness Signature/Firma del Testigo

Witness Signature/Firma del Testigo

Witness Signature/Firma del Testigo

Witness Signature/Firma del Testigo

Clinic Stamp

Immunization Unit

Stock No. C-100

Rev. 04/2017

 

Date

Vaccine

 

 

 

Mfg.

Lot No.

Site Given

Given by

Date VIS Given VIS Date

 

Hepatitis B

 

 

 

 

 

 

 

 

 

Hepatitis B

 

 

 

 

 

 

 

 

 

Hepatitis B

 

 

 

 

 

 

 

 

 

DTaP/DT/DTP/Td/Tdap

one)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DTaP/DT/DTP/Td/Tdap

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DTaP/DT/DTP/Td/Tdap

(Circle

 

 

 

 

 

 

 

DTaP/DT/DTP/Td/Tdap

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DTaP/DT/DTP/Td/Tdap

 

 

 

 

 

 

 

 

DTaP/DT/DTP/Td/Tdap

 

 

 

 

 

 

 

 

Hib

 

 

 

 

 

 

 

 

 

Hib

 

 

 

 

 

 

 

 

 

Hib

 

 

 

 

 

 

 

 

 

Hib

 

 

 

 

 

 

 

 

 

PCV

 

 

 

 

 

 

 

 

 

PCV

 

 

 

 

 

 

 

 

 

PCV

 

 

 

 

 

 

 

 

 

PCV

 

 

 

 

 

 

 

 

 

IPV/OPV

 

one)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IPV/OPV

 

(Circle

 

 

 

 

 

 

 

IPV/OPV

 

 

 

 

 

 

 

 

IPV/OPV

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

RV

 

 

 

 

 

 

 

 

 

RV

 

 

 

 

 

 

 

 

 

RV

 

 

 

 

 

 

 

 

 

MMR

 

 

 

 

 

 

 

 

 

MMR

 

 

 

 

 

 

 

 

 

Measles

 

 

 

 

 

 

 

 

 

Varicella (Chickenpox)

 

 

 

 

 

 

 

 

 

Varicella (Chickenpox)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Varicella History/Date of Varicella Disease

 

 

 

 

 

MCV4/MPSV4

 

 

 

 

 

 

 

 

 

(Circle

one)

 

 

 

 

 

 

 

MCV4/MPSV4

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Hepatitis A

 

 

 

 

 

 

 

 

 

Hepatitis A

 

 

 

 

 

 

 

 

HPV

HPV

HPV

PPSV

MenB

MenB

Influenza

Last/Apellido

First/Nombre

 

 

Middle/Segundo nombre Birth date/Fecha de nacimiento Sex/Sexo

 

 

 

(

)

 

 

 

 

 

 

 

Address/Dirección

 

 

 

 

 

 

 

Telephone Number/Número de teléfono

 

Race/Raza

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City/Ciudad

 

 

 

 

State/Estado

Zip/Código postal County/Condado

 

 

 

 

 

 

 

 

Social Security Number/Número de Seguro Social

Medicaid Number/Número de Medicaid WIC Number/Número de WIC

 

 

 

 

 

 

 

 

 

Parent’s Name/Nombre del padre o de la madre

 

 

 

 

 

 

Mother’s Maiden Name/Apellido de soltera de la madre

 

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Part # 1 of completing vaccine documentation form print

2. Right after the last section is filled out, go to type in the relevant details in all these - Witness SignatureFirma del Testigo, Witness SignatureFirma del Testigo, Clinic Stamp, Immunization Unit, and Stock No C Rev.

Ways to complete vaccine documentation form print step 2

3. The following section is all about Date, Vaccine, Mfg, Lot No, Site Given, Given by, Date VIS Given, VIS Date, e n o, e l c r i, e n o e l c r i C, and Hepatitis B Hepatitis B Hepatitis - fill in all these blanks.

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5. This final step to finish this form is pivotal. Be certain to fill out the appropriate blanks, for example LastApellido, FirstNombre, MiddleSegundo nombre Birth, AddressDirección, CityCiudad, Telephone NumberNúmero de, RaceRaza, StateEstado ZipCódigo postal, Social Security NumberNúmero de, Parents NameNombre del padre o de, and Mothers Maiden NameApellido de, before submitting. Or else, it might lead to an unfinished and probably unacceptable form!

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