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Get Providence Tdap Vaccination Declination 2011-2024

Tdap Vaccination Declination Patient Name Date of Birth Department Position I already received the Tdap vaccine at on this date Signature Date Providence has recommended that I receive Tdap vaccination to protect the patients I serve. Despite these facts I am choosing to decline Tdap vaccination right now for the following reason check one Medical Other I understand that I can change my mind at any time and accept the Tdap vaccination. I have read and fully understand the information on this declination form. Reference CDC. I acknowledge that I am aware of the following facts Children 6 years of age and younger are routinely vaccinated against tetanus diphtheria and pertussis. But older children adolescents and adults need protection from these diseases too. Td Tetanus Diphtheria and Tdap Tetanus Diphtheria Pertussis vaccines provide that protection* TETANUS Lockjaw causes painful muscle spasms usually all over the body. It can lead to tightening of the jaw muscles so the victim cannot open his mouth or swallow. Tetanus kills about 1 out of 5 people who are infected* DIPHTHERIA causes a thick covering in the back of the throat. It can lead to breathing problems paralysis heart failure and even death. PERTUSSIS Whooping Cough causes severe coughing spells vomiting and disturbed sleep* It can lead to weight loss incontinence rib fractures and passing out from violent coughing. Up to 2 in 100 adolescents and 5 in 100 adults with pertussis are hospitalized or have complications including pneumonia* These three diseases are all caused by bacteria* Diphtheria and pertussis are spread from person to person* Tetanus enters the body through cuts scratches or wounds. The United States averaged more than 1 300 cases of tetanus and 175 000 cases of diphtheria each year before vaccines. Since vaccines have been available tetanus cases have fallen by over 96 and diphtheria cases by over 99. 9. Before 2005 only children younger than 7 years of age could get pertussis vaccine. In 2004 there were more than 8 000 cases of pertussis in the U*S* among adolescents and more than 7 000 cases among adults. Recommendations of ACIP at http //www. cdc*gov/mmwr/preview/mmwrhtml/rr6007a1. htm scid rr6007a1e November 25 2011 the ACIP approved revised recommendations for healthcare personnel on use of tetanus toxoid reduced diphtheria toxoid and acellular pertussis vaccine Tdap. I acknowledge that I am aware of the following facts Children 6 years of age and younger are routinely vaccinated against tetanus diphtheria and pertussis. But older children adolescents and adults need protection from these diseases too. Td Tetanus Diphtheria and Tdap Tetanus Diphtheria Pertussis vaccines provide that protection* TETANUS Lockjaw causes painful muscle spasms usually all over the body. But older children adolescents and adults need protection from these diseases too. Td Tetanus Diphtheria and Tdap Tetanus Diphtheria Pertussis vaccines provide that protection* TETANUS Lockjaw causes painful muscle spasms usually all over the body. It can lead to tightening of the jaw muscles so the victim cannot open his mouth or swallow. Tetanus kills about 1 out of 5 people who are infected* DIPHTHERIA causes a thick covering in the back of the throat. .

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