Before completing this form,
please contact an immunization nurse at (616) 396-5266.
Vaccine Consent Forms
The Ottawa County Department of Public Health offers vaccines that protect against the following diseases:
Immunizations protect your health. Children who are not immunized are at risk for diseases which can sometimes be fatal. Children should receive most of their vaccinations by the time they are 15 months old. Additional vaccines are required before going to kindergarten and prior to starting 6th grade (about 11-12 years old.) Children should be vaccinated within the time frame that the immunizations are recommended. Children need to have a complete series of immunizations in order to be fully protected from diseases the vaccines prevent. If your child is behind, it is never too late to catch up. Call your health care provider today to get the needed vaccines.
While many people think that immunizations are for children, vaccines are important for people of all ages. Adults, depending on their age and current medical condition should receive the following: Tdap/Td, HPV, influenza, pneumonia and shingles immunizations. See Adult Vaccines or click on the Immunization Schedule for more information.
Follow the links for more information on recommended vaccine schedules:
- Immunization Schedule
- Vaccine Recommendations for Health Care Workers
- Vaccine and Travel Clinic Charges
- Vaccine Quiz
Contact your health care provider for a copy of your immunization records. If you received your immunizations in Michigan, your records may be housed in our state's Michigan Care Improvement Registry. You can contact your provider or the Ottawa County Department of Public Health to request a search. Your legal name and date of birth are required for the search. . If you received your immunizations at the Ottawa County Department of Public Health you may use this form to request your records. Other tips for locating your immunization records.
Clinic Locations & Phone Numbers
Ottawa County is served by three Department of Public Health locations. Please call the location nearest you to schedule an appointment for immunizations.
12251 James Street
Holland, MI 49423
Open Monday through Friday
Grand Haven Office
1207 South Beechtree Street
Grand Haven, MI 49417
Open Monday and Wednesday
3100 Port Sheldon Rd.
Hudsonville, MI 49426
Open Monday, Wednesday and Friday
Immunizations do not have to be expensive. The Ottawa County Department of Public Health participates with the Vaccines for Children Program which provides free vaccines to children who have no health insurance, are on Medicaid or have insurance that does not cover any part of the cost of vaccines. An administration fee is charged with each vaccine given. The fee is determined on a sliding scale based on household income and number of persons in the family. If you are concerned about the cost of immunizations for your child, please call 396-5266 and ask to speak to an immunization nurse. Many health insurance plans cover routine immunizations. Please check with your insurer. If your insurance covers the cost of immunizations, it is best to go to your physician's office to receive them. Click here to view the fees for travel and adult immunizations.
Vaccines are the single most powerful, cost-effective public health intervention ever developed. They have reduced, and in some cases, eliminated debilitating and life threatening diseases. The following websites provide resources on vaccine safety:
- Children's Hospital of Philadelphia
- The Vaccine Song
- National Network for Immunization Information
- Tdap/Td Vaccine (Tetanus, Diphtheria & Pertussis) – Tdap is recommended for all adults who have not
received a dose of Tdap vaccine with high priority for those who have
close contact with an infant younger than 12 months of age and health care workers.
Tdap should be given to pregnant women during each pregnancy (preferred during 27-36 weeks' gestation), regardless of the number of years since last Td or Tdap.
- MMR Vaccine (Measles, Mumps & Rubella) - recommended for those born on or after 1/1/57 with no documented history of receiving two doses of MMR vaccine at least one month apart .
- Hepatitis A and Hepatitis B Vaccines - recommended for those for certain high risk groups. Call for more information.
- Varicella Vaccine (Chickenpox) - recommended for those born in or after 1980 who have never had chickenpox.
- Influenza vaccine is recommended for everyone, every year.
- Pneumococcal Polysaccharide vaccine (PPSV23) – recommended for all adults over age 65 who have not previously been vaccinated. Also recommended for certain high risk individuals. Call for more information.
- Zoster (shingles) vaccine – a single dose is recommended for all adults age 60 or greater who have not previously been vaccinated. Call for more information.
Annually, 700 million travelers cross international borders and as many as 50% of them become ill. Those visiting friends and family outside of the United States have as much as 54 times the risk of contracting diseases as do other American travelers. The Ottawa County Department of Public Health believes that staying healthy while traveling involves more that just "getting shots", and that the Department of Public Health's "Travel Clinic" can help ensure your best chances for good health during your travels.
Our Travel Clinic has appointments in each of our Department of Public Health offices. During a travel clinic visit, the staff will review your trip itinerary and your medical history. You will receive the most current information specific to your trip from professional travel authorities such as Centers for Disease Control and Prevention, the World Health Organization, and Shoreland, Inc. The clinic staff will recommend and administer travel vaccines that are indicated for you, based on your medical history and the anticipated risk of exposure during your travels. You will also be provided with information and counseled on common health hazards which might be encountered on your trip, such as insect/water-borne illnesses and other non-vaccine preventable infections, recent infectious outbreaks in the area, and health care standards and health care availability at your destination. In addition, you will receive up-to-date information on safety and security alerts for your destination as well as general advice on how to remain healthy while traveling. All information will be provided in a convenient packet to take with you on your trip.
The Travel Clinic office visit fee is $70. The travel vaccinations are in addition to this fee. Payment is due at time of service. Cash, check, MasterCard, VISA, Discover Card and American Express are accepted. Please note that travel vaccines are not generally covered by insurance. However, a detailed statement will be provided to you at the time of payment which you can forward to your insurance company in the event that this expense is covered.
International Adoption Immunization & Travel Recommendations
Adoption is an exciting, rewarding and busy time for all involved. International adoption can present some additional challenges. The Ottawa County Department of Public Health's Travel Clinic offers advice on recommended and/or required immunizations for traveling to the country of your child, advice on keeping you and your family healthy while traveling and handouts on health recommendations before and after international adoption. The Centers for Disease Control and Prevention also offers more information about immunizations and international adoption.
- Vaccine Information.org
For parents and people of all ages, this webpage provides timely, accurate and proven information about vaccines and the diseases they prevent.
- Vaccine Education Center at Children’s Hospital of Philadelphia
The goal of the Vaccine Education Center is to provide concise, accurate information on all aspects of vaccines and immunization.
- Childhood Immunization
Created by the American Academy of Pediatrics, this site contains immunization information for professionals and the general public.
- Vaccines: Your best shot at good health
- Families Fighting Flu
- Sounds of Pertussis
- Voices of Meningitis
- Allied Vaccine Group
This site is comprised of links to 7 websites dedicated to presenting valid scientific information about the sometimes-confusing subject of vaccines.
- National Network
for Immunization Information (NNii)
This website provides current, science-based, extensively reviewed immunization information for health professionals and the public.
Information for parents about infectious diseases and how to prevent them
- History of Vaccines
Vaccines for Children (VFC) Program
The VFC Program provides federally purchased vaccines for children 18 years of age and younger who are Medicaid eligible, uninsured, American Indian or Alaskan Native, or are under-insured. There are many benefits for both providers and their patients to participate in this program which include keeping children in their medical home and a link to a network of experts that can provide up-to-date information on immunizations. The Vaccines for Children Program is available to Ottawa County physician offices that see children birth through 18 years of age. If you would like more information about the VFC Program, please contact Sue Schryber BSN, RN, Immunization Supervisor at: email@example.com or 616-393-5736.
Instructions for the Use of Vaccine Information Statements - Required Use
1. Provide Vaccine Information Statement (VIS) when vaccination is given.
As required under the National Childhood Vaccine Injury Act (42 U.S.C. §300aa-26), all health care providers in the United States who administer, to any child or adult, diphtheria, tetanus, pertussis, measles, mumps, rubella, polio, hepatitis A, hepatitis B, Haemophilus influenzae type b (Hib), trivalent influenza, pneumococcal conjugate, meningococcal, rotavirus, human papillomavirus (HPV), or varicella (chickenpox) vaccines shall, prior to administration of each dose of the vaccine, provide a copy to keep of the relevant current edition vaccine information materials that have been produced by the Centers for Disease Control and Prevention (CDC):
- to the parent or legal representative* of any child to whom the provider intends
to administer such vaccine, and
- to any adult to whom the provider intends to administer such vaccine. (In the case of an incompetent adult, relevant VISs shall be provided to the individual's legal representative.* If the incompetent adult is living in a long-term care facility, all relevant VISs may be provided at the time of admission, or at the time of consent if later than admission, rather than prior to each immunization.)
If there is not a single VIS for a combination vaccine, use the VISs for all component vaccines. The materials shall be supplemented with visual presentations or oral explanations, as appropriate.
2. Record information for each VIS provided.
Health care providers shall make a notation in each patient's permanent medical record at the time vaccine information materials are provided, indicating:
(1) the edition date of the Vaccine Information Statement distributed, and
(2) the date the VIS was provided.
This record keeping requirement supplements the requirement of 42 U.S.C. §300aa-25 that all health care providers administering these vaccines must record in the patient's permanent medical record (or in a permanent office log):
(3) the name, address and title of the individual who administers the vaccine,
(4) the date of administration, and
(5) the vaccine manufacturer and lot number of the vaccine used.
Availability of Copies
In Michigan: health care providers should use the Michigan versions of the VIS. Copies are available at your local Department of Public Health or at Michigan Department of Community Health. Copies are available in English and in other languages.
Immunization Education for Provider Offices
The Ottawa County Department of Public Health in conjunction with the Michigan Department of Community Health (MDCH) can provide educational in-services to provider offices to increase staffs' knowledge of immunizations. These in-services are conducted by MDCH approved Immunization Nurse Educators. They are provided free of charge and participants can receive continuing education credits. Each in-service varies in presentation length, but many can be provided over a 75 minute lunch hour. The current available modules are:
- Infant Child Update - 1.25 hours
- Adolescent Update - 1.25 hours
- Adult Update - 1.25 hours
- Vaccines Across the Lifespan - 2.25 hours
- Vaccine Management: Storage and Handling - 1 hour
- Vaccine Administration and Pain Management - 1 hour
- Vaccines for Children Program - 1.5 hours
- Influenza Update (available in the fall/early winter) - 1 hour
- Vaccinating Women Across their Lifespan OB/GYN Update - 1.25 hours
2014 Immunization In-Service Dates
January 30, 8:30 - 11:00am: Vaccinations Across the Lifespan, Ottawa County Department of Public Health, 12251 James Street, Holland, 49424
April 23, 8:30 - 10:00am: Vaccine Administration and Pain Management, Ottawa County Department of Public Health, 12251 James Street, Holland, 49424
July 17, 8:30 - 10:00am: Vaccine Management: Storage and Handling, Ottawa County Department of Public Health, 12251 James Street, Holland, 49424
September 24, 12:30 - 3:00pm: Vaccinations Across the Lifespan, Ottawa County Department of Public Health, 12251 James Street, Holland, 49424
To pre-register for one of these classes, please contact Robin Schurman, BSN, RN at 616-393-5750 or firstname.lastname@example.org
Reporting Vaccine Preventable Diseases
Please remember that all vaccine preventable diseases need to be reported to your local Department of Public Health. Visit our Disease Reporting for more information.
Great Immunization Resources for Your Office
The Michigan Department of Community Health Immunization website is a great place to download current copies of the Vaccine Information Statements (VIS) with Michigan Care Improvement Registry (MCIR) language and for foreign language VISs. This site includes information on:
- Current vaccine recommendations, schedules
- Vaccines for travel, influenza and more
- MCIR site Region 2
The Alliance in Michigan Provider Toolkit is an excellent resource for the most up to date immunization related information. The toolkit has six sections of information:
- Childhood 0-6 years
- Adolescent 7-18 years
- Adult 19 years and older
- Vaccine Safety
- Vaccine Storage and Handling; Other Resources
The Centers for Disease Control's National Immunization Program has information for providers and community members such as:
- Current vaccine recommendations
- Frequently asked questions
- Vaccines for Children program
- Immunization recommendations for healthcare workers
The Immunization Action Coalition offers a variety of helpful tools, handouts, and informational pieces for health care providers and their patients.» Back to top
Holland, MI 49424
FAX: (616) 393-5643
Clinic FAX: (616) 393-5659
8:00am - 5:00pm
Social Media Sites Policy
1207 South Beechtree Street
Grand Haven, MI 49417
Phone: (616) 846-8360
Fax: (616) 844-1778
Friday: by appointment only
3100 Port Sheldon Road
Hudsonville, MI 49426
Phone: (616) 669-0040
FAX: (616) 669-3039
Monday, Wednesday, Friday:
8am-12pm & 1pm-5pm