[PDF]Texas Department of State Health Services Addendum...
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Texas Department of State Health Services Addendum to Vaccine Information Sheet 1. 2. 3. 4. 5. 6. 7.
I agree that the person name below will get the vaccine checked below. I received or was offered a copy of the Vaccine Information Statement (VIS) for the vaccine(s) listed below. I know the risks of the disease this vaccine prevents. I know the benefits and risks of the vaccine. I have had a chance to ask questions about the disease the vaccine prevents, the vaccine, and how the vaccine is given. I know the person named below will have the vaccine put in his/her body to prevent the disease the vaccine prevents. I am an adult who can legally consent for the person named below to get the vaccine(s). I freely and voluntarily give my signed permission for this vaccine.
Patient Name: __________________________________________
Date of Birth: ______________
Patient is: (check one)
Age: ______________
[ ] Enrolled in Medicaid OR [ ] CHIP (Children’s Health Insurance Plan) [ ] Uninsured OR [ ] Underinsured (has insurance that does not pay for vaccines or caps vaccine coverage) [ ] American Indian OR [ ] Alaskan Native
Vaccine(s) to be given to child 18 YEARS OR YOUNGER: [ ] MMR 99999-4681-00 [ ] Varicella 99999-4827-00 (12 months+; Live)
(Chickenpox; 12 months+; Live)
(influenza) shot (6 months+) [ ] Hepatitis A 58160-0825-11
(IPV; 6 weeks+)
[ ] Flu
(Havrix; 12 month+)
[ ] Rotovirus 00006-4047-99
(Rototeq; 6 weeks to 8 months)
[ ] DTaP 49281-0286-10
(diphtheria, tetanus, acellular pertussis; Daptacel; 6 weeks to 7 years)
[ ] Trumenba Mening Serogroup B 10 to 25 years) 00005-0100-10
[ ] Pentacel 49281-0510-05
(DTap + IPV + Hib; 6 weeks to 4 years)
[ ] Kinrix 58160-0812-11
[ ] Inactivated polio 99999-0860-10
[ ] Flumist
(2 – 49 years old; Live)
[ ] Hib 49281-9999-99
(H. influenza B; 2 months - 5 years)
[ ] Hepatitis B 00000-0820-00
[ ] HPV 00006-4119-01
[ ] Pneumococcal 00005-1970-26
[ ] Pneumococcal
(Engerix-B; from birth)
(PCV13; Prevnar; 6 weeks to 5 years)
[ ] TDaP 99999-0400-10
(diphtheria, tetanus, acellular pertussis; Adacel; over 7 years)
(Gardasil-9; 9 to 26 years old) (PPSV23; Pneumovax; 2 years+)
[ ] Meningococcal 99999-0589-05 (MCV4, Menactra; 6 weeks+)
[ ] Bexsero Mening Serogroup B
10 to 25 years) 46028-0114-00/58160-0976-99
[ ] Pediarix 58160-0841-11
[ ] ProQuad
[ ] Varicella
[ ] Shingles
[ ] High Dose Flu shot
[ ] Inactivated polio
(Hep. B + DTap + IPV; 6 weeks to 6 years)
(MMR + Varicella; 1 to 12 years)
(DTap + IPV; 4 to 6 years)
Vaccine(s) to be given to ADULTS: [ ] MMR (up to 60 years; Live)
[ ] Flu shot (6 months+)
(Chickenpox; 12 months+; Live) (65 years+)
(Zostavax; 60 years+; Live)
[ ] Hepatitis A
[ ] Hepatitis B
(IPV; 6 weeks+) [ ] HPV
[ ] TDaP
[ ] Meningococcal
[ ] Meningococcal Serogroup B
(Havrix; 12 months+) (Boostrix, Adacel–up to 64 years; every 10 years)
(Recombivax; from birth) (MCV4, Menactra; up to 55 years old)
(Gardasil-9; 19 to 26 years old) (Trumenba; 10 to 25 years)
[ ] TB skin test (Tubersol)
[ ] Pneumococcal
[ ] Pneumococcal
[ ] Yellow fever
[ ] Typhoid oral capsule
[ ] Typhoid injection
(PCV13; Prevnar; 50 years+)
(PPSV23; Pneumovax; 2 years+)
(9 months+) (Vivotif; 6 years+) (Typhim; 2 years+) 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 the information upon request. You have the right to ask the state agency to correct any information that is determined to be incorrect. See http://www.tdh.state.tx.us 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. Texas Department of Health Services (Combined C-96, C-85, EC-87, C-90, C-92, C-106, C-97, C-95, C-108, C-91)
(Please print clearly)
IMMUNIZATION REGISTRY (ImmTrac2) Minor Consent Form
Child’s Last Name Child’s First Name Child’s Date of Birth Child’s Address City
Child’s Middle Name *Children younger than 18 years old only. Child’s Gender: Apartment #
Telephone
State Zip Code
Mother’s First Name
Male
Female
-
County
Mother’s Maiden Name
ImmTrac2, the Texas immunization registry, is a free service of the Texas Department of State Health Services (DSHS). The immunization registry is a secure and confidential service that consolidates and stores your child’s (younger than 18 years of age) immunization records. With your consent, your child’s immunization information will be included in ImmTrac2. Doctors, public health departments, schools and other authorized professionals can access your child’s immunization history to ensure that important vaccines are not missed.
The Texas Department of State Health Services encourages your voluntary participation in the Texas immunization registry.
Consent for Registration of Child and Release of Immunization Records to Authorized Entities
I understand that, by granting the consent below, I am authorizing release of the child’s immunization information to DSHS and I further understand that DSHS will include this information in the state’s central immunization registry (“ImmTrac2”). Once in ImmTrac2, the child’s immunization information may by law be accessed by: • a public health district or local health department, for public health purposes within their areas of jurisdiction; • a physician, or other health-care provider legally authorized to administer vaccines, for treating the child as a patient; • a state agency having legal custody of the child; • a Texas school or child-care facility in which the child is enrolled; • a payor, currently authorized by the Texas Department of Insurance to operate in Texas, regarding coverage for the child. I understand that I may withdraw this consent to include information on my child in the ImmTrac2 Registry and my consent to release information from the Registry at any time by written communication to the Texas Department of State Health Services, ImmTrac2 Group – MC 1946, P. O. Box 149347, Austin, Texas 78714-9347. By my signature below, I GRANT consent for registration. I wish to INCLUDE my child’s information in the Texas immunization registry. Parent, legal guardian, or managing conservator: Printed Name Date
Signature
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) Upon completion, please fax or mail form to the DSHS ImmTrac2 Group or a registered Health-care provider. Questions? (800) 252-9152 • (512) 776-7284 • Fax: (866) 624-0180 • www.ImmTrac.com Texas Department of State Health Services • ImmTrac2 Group – MC 1946 • P. O. Box 149347 • Austin, TX 78714-9347 PROVIDERS REGISTERED WITH ImmTrac2: Please enter client information in ImmTrac2 and affirm that consent has been granted. DO NOT fax to ImmTrac2. Retain this form in your client’s record. Stock No. C-7
Revised 03/2017
Patient Name:________________________________ Patient DOB:__________________________________ Contraindication to Vaccines ARE YOU ALLERGIC TO ANY OF THE FOLLOWING: YES Eggs, chicken or protein (flu/YF) Neomycin (pox, mmr, shingles) Gelatin (pox, shingles, YF) Yeast (hepB) Streptomycin or Polymyxin B (IPV) Are you moderately or severely ill (fever, cold)? (All shots)
Had serious reaction after receiving a vaccination? (All shots) Do you have cancer/leukemia, HIV/AIDS or any other immune system problems? (LAIV, MMR, VAR, ZOS) Are you on Immunosuppressant med (steroids or chemo)? (LAIV, MMR, VAR, ZOS) Have you had seizure or a brain or nervous system problem? (Flu, Td, Tdap) Have you received a blood transfusion or blood product, or been given immune (gamma) globulin or an antiviral drug? (LAIV,MMR,VAR) Women: Are you pregnant or is there a chance you could become pregnant during the next month? (MMR,LAIV, VAR, ZOS) Have you received any vaccinations in the past 28 days? ****If yes, which vaccines:
NO
