Free Tso Cai Txhaj Tshuaj Tiv Thaiv Kab Mob Tetanus-Diphtheria-Acellular Pertussis (Tdap), F-42030H - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Public Health F-42030H (3/09)

STATE OF WISCONSIN Wis. Stats. 252.04

TSO CAI TXHAJ TSHUAJ TIV THAIV KAB MOB Tetanus-Diphtheria-Acellular Pertussis (Tdap)
Cov lus tau los ntawm daim ntawv no yuav muab siv ua qhov tau txais kev tso cai txhaj koob tshuaj tiv thaiv kab mob Tdap 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 kho mob uas muaj feem kho koj tus me nyuam kom paub tseeb tias tau txhaj cov koob tshuaj tiav tas raws caij nyoog.
Qhov kos npe rau hauv qab no yog kuv tso cai muab qhov (cov) koob tshuaj nram qab no txhaj rau kuv tus me nyuam: (Kos kom tas cov lus uas hais raug)

Tshuaj txhaj tiv thaiv kab mob Tetanus, diphtheria, acellular pertussis (Tdap)

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 Caj Ces (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 cov lus hais raug)
Native American Medicaid

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

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, los yog muaj neeg tau piav rau kuv, txog tus (cov) kab mob thiab (cov) koob 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 thiab cov kev puas tsuaj uas yuav muaj tau los ntawm (cov) koob tshuaj uas yuav tsum tau txhaj thiab thov kom txhaj koob (cov) tshuaj rau kuv los yog rau tus neeg uas muaj npe nyob saud uas kuv tau tso cai 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 hais tias kuv yog ib tug uas tau txais kev pab Medicaid / BadgerCare kuv yuav tsis raug them tus nqi khiav ntaub ntawv los sis yuav tsis kom kuv pab them nyiaj ua 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 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

Hnub Kos Npe

Manufacturer________________________________________________________ Lot No. ___________________ Varicella: route= SQ site (circle one) RD or LD dose (circle one) 1 or 2

VIS date __________________

Manufacturer _______________________________________________________ Lot No.______________________

VIS date __________________

Signature and title of person administering vaccine: __________________________________________ Date vaccine administered: _________________ LHD clinic address:____________________________________________________________________________________________________________