County Of Sacramento - Immunization Assistance Program Form
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1County of Sacramento - Immunization Assistance Program
Tdap Screening and Consent Form
NOTE
:
If your child has been given a Tdap vaccine at age 7 or later, there is no need for another Tdap. Please take a proof of vaccine to your child’s school
Please Read The Following Carefully Before Signing
For you/your child to be eligible to receive Tdap vaccine, you must read, answer all questions, and sign this consent
form. Your answers to the questions listed below will help determine if you/your child will be able to receive the Tdap
vaccine. Please read the Tdap Vaccine Information Statement provided.
NAME:
____
_
_ __
BIRTHDATE: _______________ AGE: ______ SEX:
Male or Female
(First)
(Last)
(mm-dd-yyyy)
PHONE: ( _ )_____________ADDRESS:
_ _
_
_
_
CITY:
ZIP: _______
NAME OF SCHOOL
________
___
TEACHER
_____
GRADE ___________
Please circle Yes or No for the following questions and answer ALL questions.
1).Does the person have any serious allergies to medications, food, latex or other substances?
Yes
No
2) Has the person ever had a bad reaction to a vaccine in the past?
If yes, please explain: ______________________________________________________________________
Yes
No
3) Did the person ever have long or multiple seizures within 7 days after a dose of DTP or DTaP and no other
Yes
No
cause was found?
4) Does the person suffer from seizures or epilepsy?
Yes
No
5) Does the person have any medical conditions for which s/he is seeing a doctor regularly?
Yes
No
If yes, please write the medical condition(s):
I have been given a copy of the Vaccine Information Statement for the Tdap vaccine (Tdap/Td VIS, 11/18/08). I believe I
understand the benefits and risks of the vaccine and request that the vaccine indicated above be given to me or to the
person named above for whom I am authorized to sign.
Signature
Printed Name
Date
Parent’s Information – Please print clearly.
Mother’s First and Last Name: __________________________________________________
Father’s First and Last Name: ___________________________________________________
FOR CHILDREN 18 AND YOUNGER ONLY. Please complete the following information for our
Yes No
record keeping.
Is the child American Indian or Alaskan Native?
Is the child covered by CHDP or Medi‐Cal?
Does the child have private health insurance?
Is the child covered by Healthy Families?
Screening
Route/
Date:
Vaccine / Mfg:
Lot # Exp. Date:
IZ Given By:
MD/RN/LVN
Site
Tdap
IM
0.5 mL
LD
RD
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