DEPARTMENT OF HEALTH SERVICES Division of Public Health F-42029H (3/09)
STATE OF WISCONSIN Wis. Stats. 252.04
Tso Cai Rau Txhaj Tshuaj Tiv Thaiv Kab Mob Tetanus-Diphtheria-Acellular Pertussis (Tdap) thiab/los yog Tus Kab Mob Varicella
Cov lus tau los ntawm daim ntawv no yuav muab siv ua qhov tau txais kev tso cai rau txhaj koob tshuaj tiv thaiv kab mob Tdap thiab/los yog kab mob varicella nyob rau ntawm koj tus me nyuam lub tsev kawm ntawv. Cov lus no tej zaum yuav muab qhia tawm hauv Wisconsin Immunization Registry (WIR) mus rau lwm cov chaw muab kev pab kev noj qab haus huv uas muaj feem nrog xyuas koj tus me nyuam kom paub tseeb tias tau txhaj cov koob tshuaj tiav tas raws sij hawm.
Qhov kos npe rau nram qab no yog kuv tso cai muab koob (cov) tshuaj tiv thaiv kab mob no txhaj kuv tus me nyuam: (Kos kom tas cov nqe lus uas hais raug sab tom no): Tshuaj txhaj Tdap (Tetanus, diphtheria, acellular pertussis) [Yuav tsum tau txhaj (1 koob)] Tshuaj txhaj Varicella (Chickenpox) [Yuav tsum tau txhaj (2 koob)]
Tus Tau Txais Koob Tshuaj Txhaj Lub Npe (Lub Xeem, Npe, Ntawv Cim Npe Nrab)
Niam Lub Npe Hluas Nkauj (Lub Xeem, Npe, Ntawv Cim Npe Nrab)
Qhov Chaw Nyob Tus Xov Tooj Hauv Tsev ( ) Haiv Neeg (Kos rau ib qho) African American Asian
P. O. Box
Lub Zos (City)
County
Xeev
Zip Code
Hnub Yug (hli/hnub/xyoo)
Yog Poj Niam los Txiv Neej (Gender) Txiv Neej Poj Niam Pawg Neeg (Kos rau ib qho)
American Indian los yog Alaskan Native White
Lwm yam
Native Hawaiian / Pacific
Hispanic los sis Latino Tsis Yog Hispanic los sis Latino
Kev Tsim Nyog Tau Txais Yog Li Cas - Yuav tsum teb seem (section) no kom tas . (Kos kom tas txhua nqe lus hais raug)
Native American
Badger Care
Tsis Muaj Ntawv Pov Hwm Mob Nkeeg
Muaj Ntawv Tuav Pov Hwm, Them Cov Tshuaj Txhaj Muaj Ntawv Tuav Pov Hwm, Tsis Them Cov Tshuaj Txhaj
Tsim Nyog Tau Txais
Medicaid
Tus Kws Kho Mob Lub Npe
Tsev Kawm Ntawv Lub Npe
Qib Kawm (Grade)
Txheeb Tus Tau Txais Koob Tshuaj Txhaj Li Cas
Niam Txiv los sis Tus Neeg Saib Xyuas Lub Npe (Xeem, Npe, Ntawv Cim Npe Nrab)
Puas kam qhia cov koob tshuaj uas txhaj lawm pub rau Wisconsin Immunization Registry (WIR)? Kam Tsis kam
Tau muab ib daim qauv rau kuv thiab kuv tau nyeem tas lawm, los yog muaj neeg tau piav rau kuv, txog tus (cov) kab mob thiab koob (cov) tshuaj uas yuav tau txhaj. Tau muab sij hawm rau kuv nug thiab tau teb rau kuv raws li kuv lub siab xav lawm. Kuv to taub txog cov kev pab (benefits) thiab cov kev piam sij (risks) uas yuav muaj los ntawm (cov) koob tshuaj thiab kom muab koob (cov) tshuaj txhaj rau kuv los yog rau tus neeg uas muaj npe nyob saud uas kuv tau tso cai raws li qhov kom txhaj. Wisconsin Medicaid txwv tsis pub xa cov nqi rau qhov (cov) kev pab uas kam them mus rau cov neeg uas tau txais kev pab. Kuv to taub tias yog kuv yog ib tug neeg uas tau txais kev pab Medicaid / BadgerCare kuv yuav tsis raug them tus nqi khiav ntaub ntawv los sis yuav tsis kom kuv pab nyiaj rau kev khiav ntaub ntawv rau ib koob tshuaj txhaj twg li.
KOS NPE-Tus tau txais koob tshuaj txhaj los sis tus muaj cai kos npe sawv cev tus tau txais koob tshuaj txhaj
Hnub Kos Npe
X
RAU QHOV CHAW UA HAUJ LWM SIV XWB (FOR OFFICE USE ONLY) Tdap: route= IM site (circle one) RD or LD dose number= 1 VIS date ________________
Manufacturer________________________________________________________ Lot No. _____________________ Varicella: route= SQ site (circle one) RD or LD dose (circle one) 1 or 2
Manufacturer _______________________________________________________ Lot No.______________________
VIS date ________________
Signature and title of person administering vaccine: _______________________________________ Date vaccine administered: ____________________ LHD clinic address: ___________________________________________________________________________________________________________