Form F-42030h - Tso Cai Txhaj Tshuaj Tiv Thaiv Kab Mob Tetanus-Diphtheria-Acellular Pertussis (Tdap)
Download a blank fillable Form F-42030h - Tso Cai Txhaj Tshuaj Tiv Thaiv Kab Mob Tetanus-Diphtheria-Acellular Pertussis (Tdap) in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form F-42030h - Tso Cai Txhaj Tshuaj Tiv Thaiv Kab Mob Tetanus-Diphtheria-Acellular Pertussis (Tdap) with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Public Health
Wis. Stats. 252.04
F-42030H (3/09)
TSO CAI TXHAJ TSHUAJ TIV THAIV KAB MOB Tetanus-Diphtheria-Acellular Pertussis (Tdap)
Cov lus tau los ntawm daim ntawv no yuav muab siv ua qhov tau txais kev tso cai txhaj koob tshuaj tiv thaiv kab mob Tdap 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 kho mob uas muaj feem kho koj tus me nyuam kom paub tseeb tias tau txhaj cov koob tshuaj tiav
tas raws caij nyoog.
Qhov kos npe rau hauv qab no
yog kuv tso cai muab qhov (cov)
koob tshuaj nram qab no txhaj
Tshuaj txhaj tiv thaiv kab mob Tetanus, diphtheria, acellular pertussis (Tdap)
rau kuv tus me nyuam:
(Kos kom tas cov lus uas hais
raug)
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)
Caj Ces (Kos rau ib qho)
African American
American Indian los yog
H
ispanic los sis Latino
Alaskan Native
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 cov lus hais raug)
Badger Care
Native American
Muaj Ntawv Tuav Pov Hwm, Them Cov Tshuaj Txhaj
Medicaid
Tsis Muaj Ntawv Pov Hwm Mob Nkeeg
Muaj Ntawv Tuav Pov Hwm, Tsis Them Cov Tshuaj Txhaj
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)
T
Txheeb Tus
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, los yog muaj neeg tau piav rau kuv, txog tus (cov) kab mob thiab (cov) koob
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 thiab cov kev puas tsuaj uas yuav muaj tau los ntawm (cov) koob tshuaj uas yuav tsum tau txhaj thiab thov kom txhaj koob
(cov) tshuaj rau kuv los yog rau tus neeg uas muaj npe nyob saud uas kuv tau tso cai 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 hais tias kuv yog ib tug uas tau txais kev pab Medicaid / BadgerCare kuv yuav tsis raug them tus nqi khiav ntaub
ntawv los sis yuav tsis kom kuv pab them nyiaj ua 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:____________________________________________________________________________________________________________
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form F-00051h - Tso Cai Rau Txhaj Tshuaj Tiv Thaiv Kab Mob Tetanus-diphtheria-acellular Pertussis (tdap) Thiab/los Yog Tus Kab Mob Varicella, Meningococcal Conjugate (mcv4) Vaccine(s)
Medical
Form F-42029h - Tso Cai Rau Txhaj Tshuaj Tiv Thaiv Kab Mob Tetanus-diphtheria-acellular Pertussis (tdap) Thiab/los Yog Tus Kab Mob Varicella
Medical
F-00048s - Authorization To Receive Tetanus, Diphtheria, Acellular Pertussis (tdap), Meningococcal Conjugate (mcv4) And/or Human Papilloma Virus (hpv)
Legal
Form F-00048 - Authhorization To Receive Tetanus, Diphtheria, Acellular Pertussis (tdap), Menongococcal Conjugate (mcv4), Human Papilloma (hpv), And/or Influenza Vaccine(s)
Medical
Form F-42030 - Authorization To Receive Tetanus, Diphtheria, Acellular Pertussis (tdap) Vaccine
Medical
Form F-00051 - Authorization To Receive Tetanus Diphtheria Acellular Pertussis Tdap Varicella Meningococcal Conjugate Vaccine
Medical
Form F-42029 - Authorization To Receive Tetanus, Diphtheria, Acellular Pertussis (tdap) And/or Varicella Vaccine(s)
Business
Related Categories
Parent category: Legal