Print Name Date MM slash DD slash YYYY I have had the opportunity to review the latest CDC educational material (Vaccine Information Sheet Tdap 11/18/08) and ask questions regarding: 1) Tetanus, diphtheria & pertussis and their risks to health care personnel, and 2) the potential risks and benefits of the Tetanus, diphtheria & pertussis (Tdap) vaccine.Please select ONE of the following: I have received the Tdap vaccine I have received the Td vaccine Approximate date vaccine was received I have elected NOT to receive the Tdap vaccine at this time. I understand that I may elect to receive the Tdap vaccine at a later time. If so, I will contact my clinical coordinator to make arrangements for the vaccine. I understand that due to my occupational exposure to aerosol transmissible diseases, I may be at risk of acquiring an infection with pertussis. I have been given the opportunity to be vaccinated against this disease or pathogen with Tdap at no charge to me. However, I decline the Tdap vaccination at this time. I understand that by declining the Tdap vaccine, I continue to be at risk of acquiring, a serious disease. If in the future I continue to have occupational exposure to aerosol transmissible diseases and want to be vaccinated, I can receive the Tdap vaccination at no charge to me.Electronically Signed By: (please type full name)Date MM slash DD slash YYYY
