Microsoft word - sns-t29-00 region 3 naph form -flu.doc

Region 3 Strategic National Stockpile
Please PRINT the Following Information

Last Name:_______________________________________ First Name: ___________________________________________
Middle Name: ________________________ Date of Birth: ____/____/____ Age: _______ Gender: M ____ F ____

Mother’s Maiden Name: ______________________ Weight (if under 100 lbs): __________lbs.
Street Address:_______________________________ City: ________________________ State: _______ Zip: ____________
County: ___________________ E-mail (optional): ________________________________________
Home Phone: (____)______________________ Alternate Phone: (___)_________________________

Do you have flu-like symptoms today (fever, aches, chills, cough)? YES
NO (circle one)
Do you have a known latex allergy?
NO (circle one)
Are you allergic to eggs?
NO (circle one)

Are you currently pregnant or think you might be pregnant?

NO (circle one)
Are you currently breastfeeding?
NO (circle one)
List All Known Allergies:
_________________________________________________________________________________________________________ _________________________________________________________________________________________________________
Do YOU (or the minor you are filling this out for) have any of the following medical conditions?
(Circle the correct answer for each question)

Do you have or had a seizure disorder (such as epilepsy, etc.)? Do you take vitamins or supplements (Calcium, Iron, Zinc, Magnesium, Multivitamin, etc.)? Do you use antacids (Tums, Maalox, Mylanta, Rolaids, Pepto-Bismol, etc.)? Do you have an immunosuppressed medical condition (i.e. HIV/AIDS, Cancer, Lupus, Organ Transplant) Taking a Medication Containing Steroids and/or for Cancer Treatment Do you have a history of Guillian Barre Syndrome Long-term Health Problem Such As: Heart Disease, Kidney Disease, Liver Disease, Diabetes, Lung Disease, Asthma, Anemia, Other (please indicate)___________________________
List Any Medications You Are Currently Taking:
_________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________
Additional Medical Information/Concerns:
_________________________________________________________________________________________________________ _________________________________________________________________________________________________________ PARTICIPANT CONSENT OR REFUSAL TO RECEIVE VACCINATION OR MEDICATION
I HAVE: 1) been informed of reasons why I am being vaccinated/receiving medication; 2) received the vaccine/medication fact
sheet indicating the risks and benefits of the vaccine/medication, its side effects, and where I will be able to receive additional
information if side effects were to develop; 3) received information about the infectious agent; 4) had an opportunity to have my
questions answered.
CONSENT: Participant Signature/Parent or Guardian: ____________________________________ Date: ___________________

Participant Signature/Parent or Guardian: ____________________________________ Date: ___________________
To Be Filled Out For Prophylaxis Medication
Name of Medication:

TAMIFLU 75mg 1X Day
Other Medication: _________________________________________
TAMIFLU __________
Dose: ______________________________________________

Quantity Dispensed:

10 Day Supply
50 Day Supply
60 Day Supply Other____________

Manufacturer: __________________ Lot #: ______________________ Exp Date: _____________________
Did the patient receive a medication Fact sheet? (Circle one) YES

Notes (if applicable): ____________________________________________________________________________
Staff Signature: ________________________________________________ Date: __________________________
To Be Filled Out For Vaccination
Name of Vaccination (Circle One): Influenza
OTHER: ____________________________

Vaccination Site (Circle One): LEFT ARM RIGHT ARM
OTHER: ____________________________

Manufacturer: ______________________________________

Dose Amount: ______________________

Vaccine Lot #: _____________ Diluent Lot #: _____________ Batch #: _____________ Exp Date: ___________
Notes (if applicable): ____________________________________________________________________________

______________________________________________________________________________________________ ______________________________________________________________________________________________
ASK PATIENT: Have you ever received the influenza vaccine? YES NO

Did the patient receive the Vaccination Fact Sheet? (Circle one) YES NO
Staff Signature: ________________________________________________ Date: __________________________

If Patient Went to Infirmary/Received Counseling
Counseling/Treatment Given By:
Name _____________________________________________ Title: _____________________________________
What was the outcome? Clinician Notes: ___________________________________________________________



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Microsoft word - novatec 15-3-20.doc

according to Regulation (EU) No. 1907/2006 NovaTec 15-3-20 1. IDENTIFICATION OF THE SUBSTANCE/PREPARATION AND OF THE COMPANY/UNDERTAKING Product information 2. HAZARDS IDENTIFICATION Risk advice to man and the environment No particular dangers occur if the regulation/notes for storage and handling are observed. 3. COMPOSITION/INFORMATION ON INGREDIENTS Chemica

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