Tetanus, Diptheria, and
Pertussis (Tdap) Declination


Tetanus, Diptheria, and Pertussis (Tdap) for adult use is indicated for active immunization against tetanus, diphtheria, and pertussius in adults and children 7 years of age or older. Tetanus or diphtheria infection may not confer immunity; therefore, initiation or completion of active immunization is indicated at the time of recovery from these infections. A booster dose of 0.5ml of Tdap Toxoid is given ten years after completion of primary immunization and every ten years thereafter.


I understand that due to my occupational exposure to aerosol transmissible diseases, I may be at risk of acquiring an infection with pertussis. I have been given the opportunity to be vaccinated against this disease or pathogen with Tdap at no charge to me. However, I decline the Tdap vaccination at this time. I understand that by declining the Tdap vaccine, I continue to be at risk of acquiring, a serious disease. If in the future I continue to have occupational exposure to aerosol transmissible diseases and want to be vaccinated, I can receive the Tdap vaccination at no charge to me.