Department of Health and Human Services
Refusal to Stay in Clinic Setting
After Receiving a Tdap Vaccine in the
Community Mass Immunization Clinic Setting
Form for Adults
Name of client: Date vaccine administered: _____________
Name of vaccine: Time vaccine administered: _____________
← A healthcare professional has informed me that I should remain for 15-20 minutes after receiving influenza vaccine in order to be observed for signs and symptoms of an immediate adverse reaction.
← I have also been advised of the risks of an allergic reaction to the vaccine, including the inability to breathe.
← I acknowledge that I have been properly informed about the potential side effects of taking the vaccine and the risks of leaving before the recommended fifteen minutes observation.
← Notwithstanding the recommendations, and mindful of the potential adverse consequences from taking the vaccine, I decline to remain for a fifteen minute period of observation.
← I assume full responsibility for any adverse consequences which arise from my leaving prior to the recommended observation period, including a potential severe allergic reaction to the vaccine which may hinder my ability to breathe and may require emergency care.
Signature of Adult Client Date Time
____________________________________
Printed Name of Adult Client
Signature of Clinic Authority/Vaccinator Date
Reference: Epidemiology and Prevention of Vaccine-Preventable Diseases, 12th Edition; U.S. DHHS, CDC; May, 2011, Appendix D-3.
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This form is for adult clients only and shall be maintained by the Clinic.
All children less than 19 years of age must stay on site for 15-20 minutes following the vaccination to be observed for immediate adverse reactions.
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