The Texas EC 87 form is an important document used to obtain consent for the administration of the live, intranasal influenza vaccine. This form ensures that individuals or their guardians understand the benefits and risks associated with the vaccine, as well as the disease it prevents. By signing this form, they provide their authorization for the vaccine to be administered, highlighting the importance of informed consent in healthcare.
The Texas EC 87 form plays a crucial role in the vaccination process, specifically for the live, intranasal influenza vaccine. This form serves as a consent document, ensuring that individuals receiving the vaccine, or their guardians, are fully informed about the vaccine's benefits and risks. It requires the signer to acknowledge receipt of the Vaccine Information Statement (VIS), which outlines important details about the vaccine and the disease it prevents. The form also emphasizes the right to ask questions and understand the vaccination procedure. By signing, the individual confirms their legal ability to consent and grants permission for the vaccine to be administered. Additionally, the form includes sections for the provider's identification, the patient's information, and the vaccination details, such as the vaccine manufacturer and lot number. Privacy is a key consideration, with notifications about the handling of personal information and the right to review it. Overall, the Texas EC 87 form is designed to facilitate informed consent while ensuring compliance with health regulations.
Texas Department of State Health Services
Addendum to 2013-2014 Live, Intranasal Inluenza Vaccine
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 beneits 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:
Live, Intranasal Inluenza Vaccine
*STATEMENT: I authorize the release of any medical or other information necessary to process the claim. I also request payment of government beneits to the party who accepts assignment.
Provider Identiication Number: _____________________________________________________
Medicare Health Insurance Claim Number: ____________________________________________
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
For Clinic/Ofice Use
Clinic/Ofice Address:
Date Vaccine Administered:
Vaccine Manufacturer:
Vaccine Lot Number:
Site of Injection:
Signature of Vaccine Administrator:
Title of Vaccine Administrator:
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.state.tx.us for more information on Privacy Notiication. (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.
Notice: Alterations or changes to this publication is prohibited without the express written consent of the Texas Department of State Health Services, Immunization Branch.
Instructions: File this consent statement in the patient’s chart.
Texas Department of State Health Services EC-87 (07/13)
CDC Interim VIS Revision (07/26/13)
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