South Dakota - Tdap Vaccination Record Form

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2015--2016 Tdap VACCINATION RECORD
Information about person to receive vaccine (please print)
Last Name:______________________________
First Name: _____________________________
Age: _____
Sex: ___ M ___ F
Address: ______________________________ City __________________ Zip Code ______
Date of Birth _______________
Phone number __________________________
Grade ________
School ______________________________
For the child being vaccinated - check any that apply
(Check here if none apply) _____
Enrolled in Medica Please provide Medicaid #
American Indian or Alaskan Native
Does not have health insurance
Health insurance DOES NOT pay for vaccines
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 in accordance with applicable HIPAA Privacy Act standards and requirements. Immunization
records remain confidential, and any person who fails to protect the confidentiality of this information is guilty of a Class 1 misdemeanor. If you choose
NOT to have your/your child's immunization record shared with other providers, you may request a refusal form.
Please answer the following health screening questions
Don't
Yes
No
Know
1 ) Is the child sick today?___________________________________________________________________
____ ____
____
2 ) Does the child have allergies to medications, food, a vaccine component, or latex? __________________
____ ____
____
3 ) Has the child 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 problem?
____ ____
____
Children who have received a prior dose of Tdap do not need to be re-vaccinated at this time.
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 if a minor)
Date __________________
If you are completing this for your child and do not plan to attend the clinic, please provide a phone number where you could be
reached on the day/time of the clinic
for office use only
Tdap
Date/Time
Vaccine
Vaccine
Route
Site
Date of VIS
Signature of person
Manufacturer
Lot number
Circle
Publication
administering vaccine
IM
Right Deltoid
Feb.
Left Deltoid
24
2015
The Department of Health Notice of Privacy Practices can be found on the following website:
IM - Intramuscularly
Revision Date 9/21/2015

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