Form F-42029h - Tso Cai Rau Txhaj Tshuaj Tiv Thaiv Kab Mob Tetanus-Diphtheria-Acellular Pertussis (Tdap) Thiab/los Yog Tus Kab Mob Varicella
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1DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Public Health
Wis. Stats. 252.04
F-42029H (3/09)
Tso Cai Rau Txhaj Tshuaj Tiv Thaiv Kab Mob Tetanus-Diphtheria-Acellular Pertussis (Tdap)
thiab/los yog Tus Kab Mob Varicella
Cov lus tau los ntawm daim ntawv no yuav muab siv ua qhov tau txais kev tso cai rau txhaj koob tshuaj tiv thaiv kab mob Tdap thiab/los
yog kab mob varicella nyob rau ntawm koj tus me nyuam lub tsev kawm ntawv. Cov lus no tej zaum yuav muab qhia tawm hauv
Wisconsin Immunization Registry (WIR) mus rau lwm cov chaw muab kev pab kev noj qab haus huv uas muaj feem nrog xyuas koj tus
me nyuam kom paub tseeb tias tau txhaj cov koob tshuaj tiav tas raws sij hawm.
Qhov kos npe rau nram qab no yog
Tshuaj txhaj Tdap (Tetanus, diphtheria, acellular pertussis) [Yuav tsum tau txhaj (1 koob)]
kuv tso cai muab koob (cov) tshuaj
tiv thaiv kab mob no txhaj kuv tus
me nyuam:
Tshuaj txhaj Varicella (Chickenpox) [Yuav tsum tau txhaj (2 koob)]
(Kos kom tas cov nqe lus uas hais
raug sab tom no):
Tus T
Lub Npe (Lub
Niam Lub Npe Hluas Nkauj (Lub Xeem, Npe, Ntawv Cim Npe Nrab)
au Txais Koob Tshuaj Txhaj
Xeem, Npe, Ntawv Cim Npe Nrab)
Qhov Chaw Nyob
P. O. Box
Lub Zos (City)
County
Xeev
Zip Code
Tus Xov Tooj Hauv Tsev
Hnub Yug (hli/hnub/xyoo)
Yog Poj Niam los Txiv Neej (Gender)
(
)
Txiv Neej
Poj Niam
Haiv Neeg (Kos rau ib qho)
Pawg Neeg (Kos rau ib qho)
African American
American Indian los yog
H
Alaskan Native
ispanic los sis Latino
Tsis Yog H
ispanic los sis Latino
Asian
Native
White
Hawaiian / Pacific
Lwm yam
Kev Tsim Nyog Tau Txais Yog Li Cas - Yuav tsum teb seem (section) no kom tas
. (Kos kom tas txhua nqe lus hais raug)
Badger Care
Native American
Muaj Ntawv Tuav Pov Hwm, Them Cov Tshuaj Txhaj
Tsim Nyog Tau
Txais
Tsis Muaj Ntawv Pov Hwm Mob Nkeeg
Muaj Ntawv Tuav Pov Hwm, Tsis Them Cov Tshuaj Txhaj
Medicaid
Tus Kws Kho Mob Lub Npe
Tsev Kawm Ntawv Lub Npe
Qib Kawm (Grade)
Niam Txiv los sis Tus Neeg Saib Xyuas Lub Npe (Xeem, Npe, Ntawv Cim Npe Nrab)
Txheeb Tus
T
au Txais Koob Tshuaj Txhaj Li Cas
Puas kam qhia cov koob tshuaj uas txhaj lawm pub rau Wisconsin Immunization Registry (WIR)?
Kam
Tsis kam
Tau muab ib daim qauv rau kuv thiab kuv tau nyeem tas lawm, los yog muaj neeg tau piav rau kuv, txog tus (cov) kab mob thiab koob
(cov) tshuaj uas yuav tau txhaj. Tau muab sij hawm rau kuv nug thiab tau teb rau kuv raws li kuv lub siab xav lawm. Kuv to taub txog
cov kev pab (benefits) thiab cov kev piam sij (risks) uas yuav muaj los ntawm (cov) koob tshuaj thiab kom muab koob (cov) tshuaj
txhaj rau kuv los yog rau tus neeg uas muaj npe nyob saud uas kuv tau tso cai raws li qhov kom txhaj.
Wisconsin Medicaid txwv tsis pub xa cov nqi rau qhov (cov) kev pab uas kam them mus rau cov neeg uas tau txais kev pab.
Kuv to taub tias yog kuv yog ib tug neeg uas tau txais kev pab Medicaid / BadgerCare kuv yuav tsis raug them tus nqi khiav ntaub
ntawv los sis yuav tsis kom kuv pab nyiaj rau kev khiav ntaub ntawv rau ib koob tshuaj txhaj twg li.
KOS NPE-
Hnub Kos Npe
Tus tau txais koob tshuaj txhaj los sis tus muaj cai kos npe sawv cev tus tau txais koob tshuaj txhaj
X
RAU QHOV CHAW UA HAUJ LWM SIV XWB (FOR OFFICE USE ONLY)
Tdap:
route= IM site (circle one)
RD
or
LD
dose number= 1
Manufacturer________________________________________________________ Lot No. _____________________
VIS date ________________
Varicella: route= SQ site (circle one)
RD
or
LD dose (circle one)
1
or
2
Manufacturer _______________________________________________________ Lot No.______________________
VIS date ________________
Signature and title of person administering vaccine: _______________________________________ Date vaccine administered: ____________________
LHD clinic address: ___________________________________________________________________________________________________________
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