2009 h1n1 influenza vaccine consent form for use with either intramuscular, injectable formulation or live attenuated, intranasal formulation of vaccine

2010-2011 Influenza Vaccine Consent Form
Goodhue County Public Health Service
Information about Individual to Receive Vaccine (Please Print)
NAME (Last)

Month_______ Day______ Year _________

Screening for Vaccine Eligibility
The answers to the following questions will help us to determine if you can get the influenza vaccine.
Please mark YES or NO for each question.
1. Are you ill today?
2. Do you have a serious allergy to eggs? 3. Do you have any other serious allergies? Please list: ___________________________________________ 4. Have you ever had a serious reaction to a previous dose of influenza vaccine? 5. Have you ever had Guillain-Barré Syndrome? (Guillain-Barré Syndrome is a type of temporary severe muscle weakness) Your answers to the following questions will help us know which type of vaccine you can receive. (Injection or
Nasal Spray)
1. Have you gotten MMR, Chickenpox, or nasal FluMist vaccine within the past month?
Vaccine: ___________________________________ Date given: Month______Day_______Year___________ 2. Do you have any of the following: Asthma,, diabetes (or other metabolic disease), or disease of the lungs, heart, kidneys, liver, nerves, or blood? 3. Are you on long-term aspirin or aspirin-containing therapy? (For example, do you take an aspirin every day?) 4. Do you have a weak immune system? (For example, from HIV, cancer, or medications such as steroids or those used to treat cancer)? 6. Do you have close contact with a person who is hospitalized and in a protected environment? (For example, a hospitalized person who has had a bone marrow transplant) 7. Are you or have you been on an antiviral medication within the last 48 hours? 8. Is the person to be vaccinated younger than 2 years old or 50 years or older? CONSENT FOR VACCINATION:
I GIVE CONSENT to be vaccinated with the influenza vaccine. I have received the 2010-2011 Vaccine Information Statement for the influenza
vaccine and understand the risks and benefits.
I understand that the information contained within this record is being maintained to monitor immunization needs in order to prevent disease.
This information is confidential and will only be shared with organizations or persons who are authorized by law to receive it. This includes the
Minnesota Department of Health, a health care provider or health care organization providing services on behalf of the child, the child’s school or
childcare and anyone else authorized under law to receive it. This information will be included in the Minnesota Immunization Information
Connection Registry, a secure web-based registry system for health care providers. If you choose not to have your child’s information shared with
registry please call 1-800-657-3970.
Signature of person receiving vaccine or Parent/Legal Guardian:
: _____________________________________________________ Date: ___________________________
Injection Site
Vaccine Manufacturer
Lot Number
VIS Given
Name and Title of Vaccine Administrator

Source: http://co.goodhue.mn.us/departments/publichealth/files/2010SeasonalFluConsentForm.pdf

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