CA Kaiser Permanente Tetanus Diphtheria & Pertussis (Tdap) Declination Form 2015-2025 free printable template

Southern California Tetanus Diphtheria Pertussis Tdap Declination Form Print Name I acknowledge that I am aware of the following facts Whooping cough pertussis is a highly contagious respiratory tract infection. I understand that due to my occupational exposure to aerosol transmissible diseases I may be at risk of acquiring an infection with pertussis and by declining the Tdap vaccine I continue to be at risk of acquiring a serious disease.

How to fill out tdap declination form

How to fill out CA Kaiser Permanente Tetanus Diphtheria & Pertussis

1. Obtain the CA Kaiser Permanente Tetanus Diphtheria & Pertussis form from your healthcare provider or download it from the Kaiser Permanente website.
2. Fill in your personal information, including your full name, date of birth, and contact information.
3. Indicate your current health status and any allergies or medical conditions that may be relevant.
4. Confirm your vaccination history by providing details of previous Tdap vaccinations, if any.
5. Review the information you've entered for accuracy.
6. Sign and date the form to certify that the information is correct.
7. Submit the completed form to your healthcare provider or the designated location as instructed.

Who needs CA Kaiser Permanente Tetanus Diphtheria & Pertussis?

1. Individuals who are due for a booster shot.
2. Pregnant individuals in their third trimester to protect their newborn.
3. Adults in close contact with infants and young children.
4. Healthcare workers and caregivers who need protection against these diseases.

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What is CA Kaiser Permanente Tetanus Diphtheria & Pertussis?

CA Kaiser Permanente Tetanus Diphtheria & Pertussis is a health program that provides immunization against three serious diseases: tetanus, diphtheria, and pertussis (whooping cough).

Who is required to file CA Kaiser Permanente Tetanus Diphtheria & Pertussis?

Individuals including children, adolescents, and adults who are due for vaccinations or boosters for tetanus, diphtheria, and pertussis are required to file with CA Kaiser Permanente.

How to fill out CA Kaiser Permanente Tetanus Diphtheria & Pertussis?

To fill out CA Kaiser Permanente Tetanus Diphtheria & Pertussis, individuals typically need to provide personal health information, vaccination history, and consent for immunization, either through an online portal or paper form.

What is the purpose of CA Kaiser Permanente Tetanus Diphtheria & Pertussis?

The purpose of CA Kaiser Permanente Tetanus Diphtheria & Pertussis is to ensure individuals are protected against these diseases through vaccination, thereby reducing the risk of outbreaks and promoting public health.

What information must be reported on CA Kaiser Permanente Tetanus Diphtheria & Pertussis?

The information that must be reported includes the individual's name, date of birth, vaccination date, type of vaccine administered, and any adverse reactions if applicable.