Pneumococcal Vaccine Informed Consent
UPDATED Fall 2024 to include Pneumococcal Conjugate (PCV21) and to reflect the CDC Advisory Committee on Immunization Practices (ACIP) recommendation for lowering the age for pneumococcal vaccination from 65 to 50 years old.
Use this form to document that:
| • | the pneumococcal vaccine was offered to the patient/resident |
| • | the required education about the vaccine was provided to the patient/resident (or their representative) |
| • | the patient/resident (or their representative) consented to or declined the vaccine |
Size: 8 ½" x 11"
Print: 2 sides, black ink
Punching: 5 holes top and side
Packaging: 100 per pad