Fillable Form 12: Please Read and Post Free Public (Disease Prevention & Control - San Francisco Department of Public Health)

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Form 12: Please Read and Post Free Public (Disease Prevention & Control - San Francisco Department of Public Health)

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FROM: Communicable Disease Prevention Unit
San Francisco Department of Public Health
DATE: March 7, 2011
Please Read and Post
COMMUNICABLE DISEASE CONTROL AND PREVENTION
101 Grove Street Room 408 San Francisco CA 94102
Tel:415.554.2830 Fax 415.554.2579
www.sfcdcp.org
Free Public Tdap Vaccination Clinics for 7
th
– 12
th
grade students
SFDPH will hold 3 Tdap clinics open to 7
th
-12
th
graders. The clinics are scheduled for:
• Saturday, March 19, 2011 at Roosevelt Middle School
• Saturday, May 14, 2011 at John O’Connell High School
• Saturday, August 6, 2011, location TBD
These clinics are in response to the new school immunization law, AB 354 requiring students
entering grades 7-12 in the fall of 2011 to show proof of a Tdap shot before being allowed to
begin the new school year.
We are actively encouraging students (parents) to go to their doctor for their Tdap shot, as well as
other adolescent immunizations (HPV, Meningococcal, Varicella dose 2, and Influenza).
The attached documents are:
• the promotional flyer for the March 19
th
clinic
• the volunteer recruitment flyer and application
Please post and share widely.
Both can be found at http://sfcdcp.org
Thank you for your help in getting all 25,000 7
th
to 12
th
graders immunized against Pertussis in a
timely fashion.
All Students MUST come with a Parent/Guardian
or
a signed parental consent form and a non-guardian adult
Free of Charge (Tdap vaccination is a $70 value)
Parking: Available on school blacktop, enter on Palm St
Public Transit: Muni lines 44, 38, 33, 31, 2
San Francisco Department of Public Health
Free Tdap (Whooping Cough)
Vaccination Clinic
— A $70 value! —
For San Francisco students entering 7th-12th grades in Fall 2011
A new California law requires that students show proof of vaccination before
entering school this fall
For more information about the new school law and to
download the Parental Consent form visit:
www.sfcdcp.org/tdapclinics.html
Saturday, March 19th, 2011
11:00am - 4:00pm
(or until vaccine is gone)
Roosevelt Middle School
460 Arguello Blvd
(between Geary and Clement)
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!
!
!
The San Francisco Department of Public Health needs your help!
We are holding 3 mass clinics to implement a new California law that
requires all
7
th
– 12
th
grade students to get a Tdap booster before entering
school this fall.
Clinic 1
Saturday, March 19
th
9:30am – 5pm
Roosevelt Middle School
460 Arguello Boulevard
Clinic 2
Saturday, May 14
th
9:30am- 5pm
John O’Connell High School
2355 Folsom Street
Clinic 3
Saturday, August 6
th
,
Time and Location: TBD*
Lunch will be provided
Who can volunteer? Anyone 18 or older. We are looking for responsible
individuals who are willing and able to give and follow instructions, and interact
positively and politely with the public. Additional needs include licensed
healthcare providers and individuals fluent in languages other than English
How do I volunteer? Go to www.sfcdcp.org, click on the “Volunteer to Help”
section, and follow the instructions.
Types of volunteer positions: Greeters, vaccinators, line monitors, etc.
Note: Job assignments may not necessarily match skill base
Submitting a volunteer form does not guarantee a volunteer position
Sign Up BEFORE March 11
th
!
Visit www.sfcdcp.org
Thank you for your interest in keeping San Francisco healthy!
San Francisco Department of Public Health
Communicable Disease Prevention Unit
101 Grove Street, Room 408
San Francisco, CA 94102
Edwin Lee, Mayor
TdaP VACCINATION CLINICS VOLUNTEER APPLICATION
Today’s Date: __________________
Submit this form before Friday, March 11th. Submitting this form does not guarantee that you will be recruited to
work at the clinic(s). If you are needed, you will be contacted directly. Each clinic will be staffed with vaccinators,
screeners, translators, runners, and more. Job training will take place on-site. You must be at least 18 years old to
volunteer. Submit this form via email to john.willhoite@sfdph.org
or fax to 415-554-2579 before MARCH 11
th
. Call
415-554-2830 with questions.
These clinics are in response to the new Tdap vaccination law (AB 354) that requires all students in San Francisco
entering 7
th
-12 grades in Fall of 2011 to show proof of Tdap before entering school. The clinics are intended for students
between 10 – 18 years old. For more information about the new law, visit www.shotsforschool.org
. THANK YOU!
Last Name __________________________________ First Name _________________________________
Best Phone Number __________________________ Email ______________________________________
Occupation _________________________________ Title _______________________________________
Are you an employee of the City and County of San Francisco? ___ No ___ Yes (if yes, fill in box below)
Name of Department: __________________________________________________ Classification: _____________
For All Volunteers:
Clinic Availability:
Please indicate the clinic(s) where you can volunteer:
Saturday, March 19
th
, 9:30am – 5pm; Roosevelt Middle School, 460 Arguello Boulevard
Saturday, May 14
th
, 9:30am – 5pm; John O’Connell High School, 2355 Folsom Street
Saturday, August 6
th
, Times and location to be determined
Languages spoken fluently other than English (check all that apply):
Cantonese Russian Vietnamese
Korean Spanish Other: ______________________________
Mandarin Tagalog
Lifting Restrictions: __ No __ Yes; If yes, please explain: ___________________________________________
For Healthcare Providers Only:
MD Experience with vaccinations:
Physician’s Assistant / Nurse Practitioner Have administered vaccines
RN Have never administered vaccines
LVN
Pharmacist Glove size (clinicians only):
Medical Assistant Small
Other clinician: _________________________ Medium
Student: Large
Medical Extra large
Nursing
Pharmacy Do you have a latex glove allergy? __ No __ Yes
Physician’s Assistant
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Completed 10 January 2021

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