Tdap Vaccination Consent Form

Information about person to receive vaccine (please print clearly)

Last Name:____________________________ First Name:__________________________ Date of Birth:______ / ______ / ______

Address: ___________________________________ City: __________________________ State: _______ Zip: ______________

School: ___________________________ Grade: ______ Phone Number: _________________________ Age:_______________

Please answer the following health screening questions:

Don’t

Yes No Know

1.) Is the person to be vaccinated sick today?....................................................................................................................

2.) Does the person to be vaccinated have an allergy to latex or to a component in the vaccine………………………..

3.) Has the person to be vaccinated ever had a serious reaction to a vaccine in the past?.................................................

4.) Has the child, a sibling, or a parent had a seizure; has the child had brain or other nervous system problems?..........

5.) Has it been at least 5 years since the child received a tetanus containing vaccine? (DTaP, DTP, or Tdap)………...



If it has been less than 5 years, there may be an increased chance of a reaction to the vaccine such as redness, swelling, and discomfort at the injection site.

Check any below that pertain to your child:

Enrolled in Medicaid …………………………...………

Medicaid Number _______________________

Does not have health insurance ……………...…………

American Indian or Alaska Native ………...…………...

Health Insurance that DOES NOT pay for vaccines……

Consent for Vaccination:

I have been provided a copy of and have read or have had explained to me the information about Tetanus, Diphtheria, Pertussis diseases

and the Tdap vaccine. I have had a chance to ask questions that were answered to my satisfaction. I believe I understand the benefits and

the risks of the vaccine and ask that the vaccine be given to the child above for whom I am authorized to make this request.

Signature (Parent or Guardian): __________________________________________________________ Date:______ / ______ / ______

If you are completing this consent form for your child and do not plan to attend the clinic, please provide a phone number where you can

be reached on the day and time of the clinic: (

) ___________ - _______________

The South Dakota Immunization Information System (SDIIS) is an automated system to document vaccinations given in South Dakota.

SDIIS will give parents access to their child’s immunization record from any participating South Dakota provider. SDIIS also allows

providers to send reminder notices regarding needed immunizations. Health care providers, health care facilities, federal or state

agencies, welfare agencies, school or family day care facilities may have access to this information. Immunization records remain

confidential, and any person who fails to protect the confidentiality of this information is guilty of a Class 1 misdemeanor.

REFUSAL TO RELEASE INFORMATION: I have read or had explained to me the South Dakota Immunization Information System

(SDIIS). I understand the benefits of allowing my child’s immunization record to be shared with other primary care providers and public

health officials. However, if I choose NOT to have my child’s immunization record shared with other providers I will request a refusal

form.

TYPE

DATE/ TIME

VACCINE

ROUTE

SITE

DATE OF VIS

PUBLICATION

MANUFACTURER

LOT NUMBER

(circle one)

RIGHT DELTOID

Tdap

LEFT DELTOID

Signature of Person Administering the Vaccine:

10/2013

Tdap Vaccination Consent Form - South Dakota

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