Microsoft word - 2013- 14 influenza consent var eng - heritage.doc

2013-14 Influenza Vaccine Registration and Consent
VACCINE ADMINISTRATION RECORD
Information about person who will receive vaccine (please print)
Last Name
First Name
Birthdate MMDDYYYY
Address: Street
Phone Number
Previous / Maiden name

Clinic site: Heritage High School, Vancouver, WA

I have been given a copy and have read or have had explained to me the information in the Vaccine Information Statement for Influenza vaccine. I have had a chance to ask questions which were answered to my satisfaction. I believe I understand the benefits and risks of the Influenza vaccine and request that the Influenza vaccine be given to me or to the person named below for whom I am authorized to make this request. I understand that information about the immunizations will be stored electronically in a computer system, and that information from this computer system may be used by doctors, nurses, or other health care providers to help them provide health care. x_____________________________________________________________________________ Date:_____________ Signature of person receiving vaccine (or person authorized to make request – PARENT OR GUARDIAN) IF PARENT OR GUARDIAN PLEASE PRINT FULL NAME
x_____________________________________________________________________________ Date:_____________ Signature Interpreter 2013-14 Influenza Vaccine
Manufacturer
Lot #/Exp Date
Intra Nasal Spray
Intranasal
07/26/2013
_____________________________________________________________________ SIGNATURE OF VACCINE ADMINISTRATOR TITLE OF VACCINE ADMINISTRATOR ______________________________________________________________________ H\communicable disease\H:\PHEPR\Working Files\Martinez\2013- 14 Influenza consent VAR Eng - Heritage.doc Page 1 of 2 At this clinic, we will be offering the flu vaccine as a nasal spray (in the nose)

If you answer “yes” to any of the questions below, nasal spray vaccine will not be a good choice
for you. STOP and go back to PART A and answer the questions for the injection.
Answer for the person receiving the vaccine: Yes No Know
1) Is the person younger than age 2 years or older than age 49 years? 2) Is the person pregnant or could she become pregnant within the next month? 3) Is the person younger than 5 years, and a doctor has said she/he has asthma or 4) Does the person have asthma, heart disease, lung disease, or a disease of the kidneys, nerves, muscles, heart, liver or blood? 5) Does the person have a weak immune system (for example, because of HIV/AIDS, or medicine such as steroids, cancer medicine or radiation)? 6) Does the person have an allergy to eggs or a component of the flu vaccine? 7) Has the person ever had a serious reaction to a flu vaccine? 8) Is the child or teen taking aspirin every day? 9) Has the person had Guillain-Barré syndrome? 10) Does the person have close contact with someone who must be in a protected environment (such as a hospital with reverse air flow)? 11) Has the person received any other vaccinations in the past 4 weeks? Please note: Nasal spray for seasonal influenza may be given at the same time as other live vaccines. If not given at the same time should be separated by 4 weeks. 12) Has the person received antiviral medication (oseltamivir, zanamivir, Tamiflu, Relenza) recently? If yes, need to wait 48 hours after cessation of antiviral therapy before receiving live influenza vaccine. (Of note, antiviral medication should not be given until 2 weeks after receiving live virus vaccine. If antiviral medication and live virus vaccine are given at the same time, revaccination should be considered.) PAGE 2 of 2 Adapted from Seattle/King Public Health vaccine document H\communicable disease\H:\PHEPR\Working Files\Martinez\2013- 14 Influenza consent VAR Eng - Heritage.doc Page 2 of 2

Source: http://www.evergreenps.org/SchoolInfo/hhs/Documents/2013%2014%20Influenza%20consent.pdf