The Texas Addendum To Tdap Vaccine form is a crucial document that ensures individuals receive the Tetanus and Diphtheria vaccine with informed consent. This form outlines the rights and responsibilities of both the vaccine recipient and the person providing consent, emphasizing the importance of understanding the vaccine's benefits and risks. By signing this addendum, individuals confirm their agreement to proceed with the vaccination while acknowledging their awareness of the associated information.
The Texas Addendum To Tdap Vaccine form serves as a crucial document in the vaccination process for Tetanus and Diphtheria (Td). This form not only confirms the recipient's consent but also ensures that they are well-informed about the vaccine and the disease it prevents. By signing this addendum, the individual or their authorized representative acknowledges that they have received the Vaccine Information Statement (VIS), which outlines the benefits and risks associated with the vaccine. It also emphasizes the importance of understanding the disease and the vaccination process. Personal details, such as the recipient's name, birthdate, and address, are collected to ensure accurate record-keeping. Additionally, the form includes a privacy notification, highlighting the rights individuals have regarding their personal information collected by the state. The signature of the individual receiving the vaccine or their guardian is required, affirming that consent is given freely and voluntarily. This form is essential not only for legal compliance but also for fostering informed decision-making regarding vaccinations.
Addendum to Td Vaccine (Tetanus and Diphtheria) Vaccine Information Statement
1.I agree that the person named below will get the vaccine checked below.
2.I received or was offered a copy of the Vaccine Information Statement (VIS) for the vaccine listed above.
3.I know the risks of the disease this vaccine prevents.
4.I know the benefits and risks of the vaccine.
5.I have had a chance to ask questions about the disease the vaccine prevents, the vaccine, and how the vaccine is given.
6.I know that the person named below will have the vaccine put in his/her body to prevent the disease this vaccine prevents.
7.I am an adult who can legally consent for the person named below to get the vaccine. I freely and voluntarily give my signed permission for this vaccine.
Vaccine to be given:
Tetanus and Diphtheria (Td)
Tetanus
Information about person to receive vaccine (Please print)
Name: Last
First
Middle Initial
Birthdate
Sex
(mm/dd/yy)
(circle one)
M
F
Address: Street
City
County
State
Zip
TX
Signature of person to receive vaccine or person authorized to make the request (parent or guardian):
x
Date:
Witness
PRIVACY NOTIFICATION - With few exceptions, you have the right to request and be informed about information that the State of Texas collects about you. You are entitled to receive and review the information upon request. You also have the right to ask the state agency to correct any information that is determined to be incorrect. See http://www.dshs.texas.gov for more information on Privacy Notification. (Reference: Government Code, Section 552.021, 552.023, 559.003, and 559.004)
Privacy Notice: I acknowledge that I have received a copy of my immunization provider’s HIPAA Privacy Notice.
For Clinic / Office Use Only
Clinic / Office Address:
Date Vaccine Administered:
Vaccine Manufacturer:
Vaccine Lot Number:
Site of Injection:
Title of Vaccine Administrator:
Signature of Vaccine Administrator:
Date VIS Given:
Notice: Alterations or changes to this publication is prohibited without the express written consent of the Texas Department of State Health Services, Immunization Unit.
Instructions: File this consent statement in the patient’s chart.
Immunization Unit
CDC VIS Revision 04/11/2017
C-94 (07/17)
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