I have been provided a copy of the Tdap (tetanus, diphtheria and acellular pertussis) Vaccine Information Statement that discusses the specific risks and benefits of the vaccine and consent to its administration. I have had an opportunity to ask questions. I understand that this is a one-time booster dose and I acknowledge that I have not had a dose of tetanus and diphtheria Vaccine (Td) in the past 2 years. As with all medical treatment, there is no guarantee that I will become immune or that I will not experience an adverse side effect from the vaccine. I request that this vaccine be given to me.

I understand that due to occupational exposure, I may be at risk of acquiring pertussis (Whooping Cough). I have been given the opportunity to be vaccinated with Tdap (tetanus, diphtheria, acellular pertussis) vaccine at no charge from my employer. However, I decline Tdap vaccination at this time. I understand that by declining this vaccine, I continue to be at risk of acquiring any of these diseases including pertussis. If in the future I continue to have occupational exposure and I want to be vaccinated with Tdap, I can receive the vaccination series at no charge from my employer.