Vaccine Documentation Form PDF Details

The increasing number of vaccines available today presents many questions for those considering immunization. How effective are the vaccines? What are the potential risks and side effects? Do I need a vaccine documentation form for my records? Keeping up with this latest information can be overwhelming, so it is important to keep accurate records of all your vaccinations in order to remain safe and healthy. In this blog post, we’ll discuss why having a vaccine documentation form is essential and provide tips on how to ensure you have all the necessary medical documents ready when needed.

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

 

How to Edit Vaccine Documentation Form Online for Free

You'll be able to work with tx vaccine documentation form effectively by using our PDF editor online. To retain our editor on the leading edge of efficiency, we aim to adopt user-driven features and improvements regularly. We are always looking for suggestions - help us with remolding PDF editing. To get started on your journey, consider these basic steps:

Step 1: Click on the "Get Form" button above on this webpage to access our PDF editor.

Step 2: With our handy PDF tool, you can actually accomplish more than just complete blanks. Express yourself and make your forms appear high-quality with custom textual content added, or modify the file's original content to excellence - all comes along with the capability to add stunning images and sign the PDF off.

This PDF form needs specific details; to ensure accuracy and reliability, please make sure to bear in mind the guidelines further down:

1. While filling out the tx vaccine documentation form, ensure to incorporate all essential blanks in its associated part. It will help facilitate the process, enabling your information to be processed promptly and properly.

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.

Part number 3 in completing vaccine documentation form print

4. All set to complete this fourth segment! In this case you'll get all these Hepatitis B Hepatitis B Hepatitis, e l c r i C, and e n o fields to do.

Step number 4 in filling in vaccine documentation form print

It's easy to make errors when filling in your Hepatitis B Hepatitis B Hepatitis, thus be sure you reread it prior to when you finalize the form.

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!

Filling out section 5 of vaccine documentation form print

Step 3: Make sure the information is correct and press "Done" to conclude the project. Right after registering a7-day free trial account at FormsPal, you will be able to download tx vaccine documentation form or send it via email directly. The PDF file will also be available via your personal account menu with your each and every change. We don't share or sell the information that you type in whenever working with forms at our site.