Fillable State-Purchased Tdap Vaccine is Available at No Cost (Disease Prevention & Control - San Francisco Department of Public Health)

Fill Online, Printable, Fillable, Blank State-Purchased Tdap Vaccine is Available at No Cost (Disease Prevention & Control - San Francisco Department of Public Health) Form

Use Fill to complete blank online DISEASE PREVENTION & CONTROL - SAN FRANCISCO DEPARTMENT OF PUBLIC HEALTH pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

State-Purchased Tdap Vaccine is Available at No Cost (Disease Prevention & Control - San Francisco Department of Public Health)

On average this form takes 7 minutes to complete

The State-Purchased Tdap Vaccine is Available at No Cost (Disease Prevention & Control - San Francisco Department of Public Health) form is 3 pages long and contains:

  • 0 signatures
  • 12 check-boxes
  • 22 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Disease Prevention & Control - San Francisco Department of Public Health forms online.

BROWSE DISEASE PREVENTION & CONTROL - SAN FRANCISCO DEPARTMENT OF PUBLIC HEALTH FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
State-Purchased Tdap Vaccine is Available at No Cost for Prenatal Care Providers
For Use with Pregnant Patients and Their Close Contacts
The San Francisco Department of Public Health has a limited supply of state-purchased Tdap vaccine available at no
cost to San Francisco prenatal care practices.
TDAP VACCINATION IS RECOMMENDED DURING EVERY PREGNANCY AND FOR CLOSE CONTACTS
Infants are at greatest risk of developing severe complications from pertussis, including pneumonia,
encephalopathy and meningoencephalitis. Immunizing pregnant women during their third trimester provides
infants with passive immunity, giving them short-term protection against whooping cough until they are old
enough to be vaccinated.
The Advisory Committee on Immunization Practices (ACIP) ¹ and ACOG² recommend that all pregnant
women receive a dose of Tetanus, Diphtheria, and Acellular Pertussis (Tdap) Vaccine during the 3rd
trimester of every pregnancy.
Adolescents and adults who have or anticipate having contact with an infant aged <12 months should
receive a dose of Tdap if they have not received Tdap previously. Since pertussis immunity wanes within a
few years after immunization, Tdap revaccination of close contacts is a safe and immunogenic strategy.
3
STATE-PURCHASED TDAP ELIGIBILITY REQUIREMENTS
Tdap vaccine made available by SFDPH must be used exclusively for pregnant women and their close
contacts, and can be administered regardless of insurance status.
Providers must store Tdap in refrigerator-only unit(s) that meet the California Department of Public Health
(CDPH) Immunization Branch Vaccine Storage Equipment Requirements. Providers must agree and be able
to store, handle, and administer vaccine according to CDPH guidelines, described at www.eziz.org/vaccine-
storage/
Interested providers should complete a brief online survey by Friday, February 20th to assess their practices’
current storage and handling practices: www.sfcdcp.org/tdapsurvey. Providers may also complete and fax
back a hard copy to 415-554-2854. SFDPH will follow up to schedule site visits with all eligible providers.
Providers receiving free Tdap will be asked to bi-annually report the number of Tdap doses administered by
age category as well as their current vaccine inventory.
Please call the Immunization Program at 415-554-2798 or send an email to erin.bachus@sfdph.org with any questions.
1. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6207a4.htm
2. http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Update-on-Immunization-
and-Pregnancy-Tetanus-Diphtheria-and-Pertussis-Vaccination
3. Ibid.
4.
5.
6.
FROM: Communicable Disease Prevention Unit
Population Health Division
San Francisco Department of Public Health
DATE: February 4, 2015
Please Read and Post
COMMUNICABLE DISEASE PREVENTION UNIT
Disease Prevention & Control Branch, Population Health Division
San Francisco Department of Public Health
101 Grove Street Room 408 San Francisco CA 94102
Tel: 415.554.2955 | Fax 415.554.2579 | www.sfcdcp.org
Page 1
State-Purchased Tdap for Prenatal Care Providers: SurveyState-Purchased Tdap for Prenatal Care Providers: SurveyState-Purchased Tdap for Prenatal Care Providers: SurveyState-Purchased Tdap for Prenatal Care Providers: Survey
1. What type of refrigerator does your practice use to store vaccines?
2. Which of the following features apply to the thermometer your practice uses to
monitor refrigerator temperatures?
3. How often does your practice record refrigerator temperatures?
4. Which vaccines does your practice currently administer?
*
*
*
*
Stand
alonerefrigerator
gfedc
Combinationrefrigerator/freezerwithseparateexternaldoors(i.e.household
orcommercial
style)
gfedc
Combinationrefrigerator/freezerwithoutseparateexternaldoors(i.e.dormitory
orbar
style)
gfedc
Other(pleasespecify)
Digitalthermometerwiththedisplayplacedoutsidetherefrigeratorunit
gfedc
Hasaglycol
encasedprobe
gfedc
Hasavisualoraudiblealarmtosignalout
of
rangetemperatures
gfedc
Iscalibratedannually(orasoftenasthemanufacturerrecommends)
gfedc
HasavalidCertificateofTraceabilityandCalibrationTesting
gfedc
Non
digitalthermometer
gfedc
Other(pleasespecify)
Wedonotregularlyrecordtemperatures
nmlkj
Oncedaily
nmlkj
Twicedailyormore
nmlkj
Other(pleasespecify)
Tdap
gfedc
Flu
gfedc
HPV
gfedc
Other(pleasespecify)
Page 2
State-Purchased Tdap for Prenatal Care Providers: SurveyState-Purchased Tdap for Prenatal Care Providers: SurveyState-Purchased Tdap for Prenatal Care Providers: SurveyState-Purchased Tdap for Prenatal Care Providers: Survey
5. If your practice is considered a good candidate for receiving state
purchased Tdap,
SFDPH will need to conduct a site visit lasting approximately one
hour to confirm
eligibility. Can your practice commit to having a site visit?
6. If your practice receives state
purchased Tdap from SFDPH, you will need to
complete a simple usage report one or two times during the year. Can you commit to
completing a usage report?
7. If your practice receives state
purchased Tdap from SFDPH, you may only charge an
administration fee up to $26.03 per dose administered, and may not charge the vaccinee or
any third
party insurer for the vaccine itself. Can you agree to this?
8. If your practice already administers vaccines, please list the name and contact
information for the Vaccine Coordinator [i.e. primary person responsible for ordering
vaccines, conducting inventory, and managing storage and handling].
9. Who should SFDPH staff contact to follow
up on this survey and schedule a site visit
(if applicable)?
*
*
*
*
Name:
Title:
Phone#:
Email:
Besttimestoreachthis
person(listdaysofweekand
timesofday):
Yes
nmlkj
No
nmlkj
Other(pleasespecify)
Yes
nmlkj
No
nmlkj
Other(pleasespecify)
Yes
nmlkj
No
nmlkj
Other(pleasespecify)
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

State-Purchased Tdap Vaccine is Available at No Cost (Disease Prevention & Control - San Francisco Department of Public Health)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 10 January 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document