Optional Forms for Health Care Providers

These forms may be used by health care providers to clearly document for schools the records of immunization with Tdap (pertussis booster) vaccine to help meet the new Tdap requirement for attendance in 7th through 12th Grades in California during the 2011-2012 school year (and only in 7th Grade in 2012-13 and future school years).

When used, these forms are to be completed by health care providers and provided to schools by families of patients affected by the new requirement.  As these supplemental forms are intended to be utilized at schools, make sure that a separate record that describes all of the patient’s immunizations, including Tdap, is also accessible to both the medical chart and the patient or family.

Two versions are available – enter your VFC PIN and zip code to access:

• Tdap Administration: can record information about Tdap immunization of up to 2 patients on a single sheet, which can then be cut in half as desired.
• Medical Exemption or Tdap Administration: allows a licensed physician to indicate to a school that the patient has a rare contraindication to Tdap immunization. While this form also has Tdap administration information fields, only the student name and one of the two sections, either the administration or the exemption information, needs to be filled out for each student.

Fillable form options: The forms may be filled out by hand or electronically, but any information filled in electronically cannot be saved – make sure to print a copy before either closing the file or typing over information about a different patient.

As examples, a physician or clinic may:

1. Enter the physician’s or clinic’s name and address electronically, print out the form, make multiple photocopies, and then complete each patient’s name, birthdate and Tdap immunization information by hand; or
2. Print out the form, rubber stamp the physician’s or clinic’s name and address in the appropriate box, make multiple photocopies, and then complete each patient’s name and Tdap  immunization information by hand; or
3. Complete the form through any other combination of electronic and handwritten entry.