Microsoft word - 2009 h1n1 influenza vaccine consent form student.docx

2009 H1N1 Influenza Vaccine Consent Form STUDENT

Section 1: Information about Child to Receive Vaccine (please print)

STUDENT’S NAME (Last)
STUDENT’S DATE OF BIRTH
month_________ day________ year __________
PARENT/LEGAL GUARDIAN’S NAME (Last)
STUDENT’S AGE
STUDENT’S GENDER
PARENT/GUARDIAN DAYTIME PHONE
CITY STATE
SCHOOL NAME
Medicare #
Medicaid #

Section 2: Screening for Vaccine Eligibility
If your child has already been vaccinated with 2009 H1N1 influenza vaccine, please tell us the number of doses and dates of vaccination.
 Dose 1
Date received: month ____day____year_______ Date received: month ____day____year_______
The following questions will help us to know if the person being immunized can get the 2009 H1N1 influenza vaccine.
Please mark Yes or No for each question.
1. Does your child have a serious allergy to eggs? 2. Does your child have any other serious allergies? Please list: 3. Has your child ever had a serious reaction to a previous dose of flu vaccine? 4. Has your child ever had Guillain-Barré Syndrome (a type of temporary severe muscle weakness) within 6 weeks of receiving flu vaccine?
There are two types of 2009 H1N1 influenza vaccine. Your answers to the following questions will help us know which type your child can
get.
Has your child been given any vaccines, including any flu vaccine within the past 30 days? Vaccine: ___________________________________ Date given: month______day_______year___________
Does your child have any of the following: recurrent wheezing, asthma, diabetes (or other type of metabolic disease), or disease of the lungs, heart, kidneys, liver, nerves, or blood? 3. Is your child on long-term aspirin or aspirin-containing therapy (for example, does your child take aspirin every day)? 4. Does your child have a weak immune system (for example, from HIV, cancer, or medications such as steroids or those used to treat cancer)? 6. Does your child have close contact with a person who needs care in a protected environment (for example, someone who has recently had a 7. Has your child taken any influenza antiviral medications in the last week (ex.Tamiflu, Relenza)? If yes, when? 8. I authorize Washtenaw County Public Health Department to release this immunization record to the Michigan Care Improvement Registry, appropriate daycare, school personnel, employer or the healthcare provider(s) as needed
Section 3: Consent

I GIVE CONSENT to the STATE/LOCAL health department and its staff CONSENT FOR VACCINATION: I have read or had explained to me the
Vaccine Information Statement for the 2009 H1N1 influenza vaccine and for my child named at the top of this form to be vaccinated with this Signature:___________ ________________________________ TYPE OF VACCINE REQUESTED:
Date: month_____________day__________year_____________ Nasal  Injectable  No Preference 

Source: http://www.wlps.net/H1N1/2009%20H1N1%20Influenza%20Vaccine%20Consent%20Form%20STUDENT.pdf