2012 / 2013 INFLUENZA VACCINE CONSENT FORM & ADMINISTATION RECORD Section 1: Information to Receive Vaccine (please print) * Complete both sides of form. * NAME (Last) BIRTHDATE: DAYTIME PHONE NUMBER: Parent Name: Section 2: Self Screening Checklist: (All questions below pertain to the person named in Section 1.) * Injectable and intranasal forms of 2012 / 2013 influenza vaccination will be based on clinic availability and the following questions. A. If you answer “YES” to any of the following questions, you will NOT be able to receive any influenza vaccine today.
1. Do you have a severe allergy to eggs or previous dose of flu vaccine?
2. Are you moderately or severely ill today? (get vaccinated when feeling better)
3. Do you have any severe or life threatening allergies or severe allergy to any vaccine component?
4. Have you ever had Guillain-Barré Syndrome (a type of temporary severe muscle weakness)?
5. Are you younger than 6 months of age?
B. These questions will determine if you will be able to receive the FluMist intranasal vaccine when available. If you answer “YES” to any of the following questions, you will NOT be able to receive the intranasal vaccine and will need injectable vaccine.
1. I am or under 2 years or over 50 years of age.
2. I have one of the following conditions: pregnancy, kidney disease, heart disease, blood disorders including anemia, lung disease
including asthma and COPD, metabolic disease including diabetes and liver disease, neuromuscular conditions that make breathing difficult, have a weakened immune system caused by cancer or cancer treatment, HIV/AIDS, steroid or aspirin therapy. 3. I have taken any antiviral medication (such as Tamiflu or Relenza) for flu symptoms in the last 48 hours.
4. I have received other live virus vaccines in the past 28 days (ex: MMR vaccine, chickenpox vaccine, or nasal spray flu vaccine).
5. Is your nose stuffed up today? (wait until it clears up)
6. Do you care for a family member or person who is severely immunocompromised such that they need to be hospitalized in
Section 3: Complete for children less than 9 years of age If you answer “NO” to either question, your child will need two dose of the 2012 / 2013 influenza vaccine this year.
1. My child has received flu vaccine before.
2. My child has received at least two doses of flu vaccine since 2010.
Section 4: Consent CONSENT FOR VACCINATION: I have read or had explained to me the 2012 / 2013 Vaccine Information Statement for the 2012 / 2013 influenza vaccine and understand the risks and benefits. I GIVE CONSENT to Renville County Public Health to vaccinate the person named above and record in the state’s immunization registry (MIIC). If the person named above is a minor child, I attest I am the child’s parent, authorized representative, or legal guardian and may provide consent for the immunization(s). I understand that if my child is under age nine (9), my child may need to receive two doses of 2012 / 2013 influenza vaccine spaced at least one month apart. This signature serves as consent for second dose if needed.
(If this consent form is not completely filled out, signed, and dated, you or your child will not be vaccinated)
Signature (or Signature of Parent if applicable):________________________________ Date:______________________ Section 5: Vaccination Record: FOR ADMINISTRATIVE USE ONLY Date on VIS: 07/2/12 Intranasal Renville County Public Health Services Office Address: 105 S Fifth Street, Olivia, MN 56277 320-523-2570 Dose 1: Date and Nurse’s Signature Dose 2 (if applicable): Date and Nurse’s Signature Payment Information: Complete for children receiving vaccination. Renville County Public Health will be billing the following insurances for vaccine administration. No Insurance / underinsured. $14 donation requested. Checks payable to “Renville County PHS” Medicare ID #_________________________________________________ Medical Assistance ID #_________________________________________ MN Care ID # _________________________________________________ Blue Cross Blue Shield Subscriber ID#_____________________________ Insurance Subscriber Name____________________________________ Other Insurance Company Name________________________________________________ Insurance Subscriber Name______________________________________ ID #________________________________________
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