Get Tdap Documentation Form

Documentation of Tdap Administration or Medical Exemption Optional Form for Health Care Providers A Administration of Tdap DATE OF Tdap PL E STUDENT NAME Last First Middle NAME OF CHILD S PHYSICIAN OR AGENCY WHERE Tdap ADMINISTERED MM / DD / 2 0 YYYY DATE OF BIRTH B Medical Exemption to Tdap EX A Contraindications to Tdap M signature not required It is very rare for children to be given a medical exemption for school immunization requirements by their physicians. Most medical practices have no children with medical conditions that would preclude immunization with Tdap* The only contraindications to immunization with Tdap both rare are a documented history of anaphylaxis after receipt of Tdap DTaP or their ingredients or encephalopathy occurring within 7 days after immunization against pertussis that was not due to another identifiable cause Exemption Due to Medical Condition I certify that the child has a permanent medical condition described below which prevents immunization against pertussis. I understand that for the protection of the child and other students the child may be excluded from attending school for prolonged periods during each outbreak of pertussis or after each exposure to someone with pertussis. 17 CCR 6060 History of anaphylaxis after immunization with DTaP History of encephalopathy after immunization against pertussis not due to other identifiable cause Other description needed Signature of physician Date Other provider documentation of a history of Tdap administration e*g* yellow card registry or medical records will be accepted* IMM-1037 1-11. Most medical practices have no children with medical conditions that would preclude immunization with Tdap* The only contraindications to immunization with Tdap both rare are a documented history of anaphylaxis after receipt of Tdap DTaP or their ingredients or encephalopathy occurring within 7 days after immunization against pertussis that was not due to another identifiable cause Exemption Due to Medical Condition I certify that the child has a permanent medical condition described below which prevents immunization against pertussis. I understand that for the protection of the child and other students the child may be excluded from attending school for prolonged periods during each outbreak of pertussis or after each exposure to someone with pertussis. I understand that for the protection of the child and other students the child may be excluded from attending school for prolonged periods during each outbreak of pertussis or after each exposure to someone with pertussis. 17 CCR 6060 History of anaphylaxis after immunization with DTaP History of encephalopathy after immunization against pertussis not due to other identifiable cause Other description needed Signature of physician Date Other provider documentation of a history of Tdap administration e*g* yellow card registry or medical records will be accepted* IMM-1037 1-11. Most medical practices have no children with medical conditions that would preclude immunization with Tdap* The only contraindications to immunization with Tdap both rare are a documented history of anaphylaxis after receipt of Tdap DTaP or their ingredients or encephalopathy occurring within 7 days after immunization against pertussis that was not due to another identifiable cause Exemption Due to Medical Condition I certify that the child has a permanent medical condition described below which prevents immunization against pertussis. I understand that for the protection of the child and other students the child may be excluded from attending school for prolonged periods during each outbreak of pertussis or after each exposure to someone with pertussis. 17 CCR 6060 History of anaphylaxis after immunization with DTaP History of encephalopathy after immunization against pertussis not due to other identifiable cause Other description needed Signature of physician Date Other provider documentation of a history of Tdap administration e*g* yellow card registry or medical records will be accepted* IMM-1037 1-11.