Student Tdap Vaccination Consent Form

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STUDENT Tdap VACCINATION CONSENT FORM
Name:
___________
Health Department Use Only
Last
First
Middle
CI #: _______
Date of Birth:
/
/
Age:
Gender:
M
F
Encounter #:
______
If minor - parent/guardian’s name:
__
Receipt #:
Last
First
M.I.
Parent/Guardian’s Date of Birth:
Parent’s SSN:
/
/
-
-
optional
Address:
City:
ZIP:
Grade:
Home Room Teacher:
School:
Home: _________________ Cell: _______________ Work: _________________
IMPORTANT Parent/Guardian Phone #
Emergency Contact
Emergency contact number
:
:
(If other than Head of Household)
Please check YES or NO to all of the questions below to determine if your child can receive the Tdap vaccine. The nurse
giving the vaccine will review this information on the vaccine clinic day.
YES
NO
 
1. Has your child ever had a life threatening allergic reaction after a dose of any tetanus, diphtheria, or
pertussis containing vaccine?
 
2. Does your child have a severe allergy to any component of the Tdap vaccine?
 
Did your child experience a coma, or long or multiple seizures within seven days following a
3.
dose of DTP or DTaP?
Does your child have epilepsy or another nervous system problem; ever had severe swelling
4.
 
or severe pain after a previous dose of DTP, DTaP, DT, or Td; or ever had Guillain-Barré
Syndrome (GBS)? If so, consult your doctor about receiving Tdap vaccine.
If you answered YES to any of the questions above Tdap vaccine may not be safe for
your child and s/he WILL NOT receive this vaccine at school.
NOTICE OF DEEMED CONSENT FOR HIV, HEPATITIS B OR C TESTING
VDH is required by § 32.1-45.1 of the Code of Virginia (1950), as amended, to give you the following notice:
1. If any VDH health care professional, worker or employee should be directly exposed to your child’s blood or body fluids in a way
that may transmit disease, I understand that the law requires my child to give a venous blood sample for further tests. I understand that
the tests to be performed are for human immunodeficiency virus (HIV), as well as for Hepatitis B and C. A physician or other health
care provider will tell you the result of the test. 2. If your child should be directly exposed to blood or body fluids of a VDH health
care professional, worker or employee in a way that may transmit disease, that person’s blood will be tested for infection with human
immunodeficiency virus (HIV), as well as for Hepatitis B and C. A physician or other health care provider will tell you and that
person the result of the test.
Turn to the back of the form

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