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Part 1, Chapter 12: Manual Appendix VIII

Consent Form

I have been provided information about the following infectious diseases and vaccines:  (Check the appropriate disease/vaccine)

_______________________ Influenza and influenza vaccine
_______________________ Hepatitis B and Hepatitis B vaccine
_______________________ Measles, mumps and rubella and measles, mumps and rubella vaccines
_______________________ Diphtheria and tetanus and Td vaccines
_______________________ Other

I read this information and any questions I had about these diseases and vaccines were satisfactorily discussed with me.

Furthermore, I read and understand the Indian Health Service (IHS) Employee Immunization Policy.

My immunization status has been reviewed and evaluated by an appropriate IHS health professional.

Based on the information provided me, the review and evaluation of my immunization status, and the recommendation of Dr._____________________________________________, I consent to receive the following (Check the appropriate vaccine)

_______________________ Inf1uenza
_______________________ Pneumococcal
_______________________ Hepatitis B
_______________________ Measles - Mumps - Rubella
_______________________ Rubella
_______________________ Measles
_______________________ Measles - Rubella (MR)
_______________________ Tetanus
_______________________ Tetanus - Diphtheria (TD)
_______________________ Other

Witness:____________________________________ Employee:_________________________________________