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2013-2014 seasonal flumist vaccine consent form

2013-2014 Seasonal FluMist Vaccine Consent Form
PLEASE COMPLETE THE INFORMATION BELOW (Unreadable and incomplete forms may not be accepted.)
Please return signed form even if you do not want your child to participate.
Full Legal Name of Student (First Name, Middle Initial, Last Name) PLEASE PRINT
Name of School
Parent/Guardian Name (First Name, Middle Initial, Last Name) Relationship to Student
Homeroom Teacher / Grade
Birth Date (month, date, year) Age Sex
City Zip Code
Home Phone # Cell Phone #
Demographic Information: (Circle one) White American Indian/ Native Alaskan Black Asian Hispanic Other
No Insurance Medicaid Other If other, please fill out the following questions pertaining to your child’s insurance:
All answers will be kept confidential.
Insurance Company:
Member ID:
Policy Holder’s Name: Policy Holder’s Relationship to Student:
QUESTIONS: CHECK YES, NO, OR UNSURE FOR EACH QUESTION
1. Do any of the following apply to your child? (If you answer YES, your child cannot receive FluMist unless approved by your child’s doctor)
 Allergic reaction to chicken eggs or egg products  Life threatening reactions to flu vaccine in the past Has HIV/AIDS or cancer or has received an organ transplant  Currently receiving aspirin or aspirin-containing therapy  Has long-term health problems with weakened immune system,  Currently has active asthma (regularly taking asthma medication)
heart disease, lung disease (e.g. cystic fibrosis), liver disease,  Has had Guillain-Barré syndrome (very rare) kidney disease, or metabolic disorders (e.g. diabetes) or blood disorders (e.g. sickle disease or thalassemia)  Has other severe chronic health conditions Yes No Unsure
2. Will your child have close contact with a person with a severely weakened immune system?
(example: protective sterile hospital environment for bone marrow transplant) Yes No Unsure
3. In the last 4 months, has your child received one of the following vaccines: MMR, MMRV, and/or Chicken pox vaccine?
(These vaccinations typically apply to children 6 years old and younger.) Yes No Unsure
4. If your child is 8 or under, has he/she been vaccinated for flu more than once before?
I have received, read, and understand the CDC Vaccine Information Statement for the live attenuated intranasal flu vaccine (FluMist) and the Notice of Privacy Practices. I have read this document and understand the risk and benefits of the FluMist vaccine. I give permission to the State of Florida, Department of Health to give my child the first and second dose (if needed) of the vaccine in my absence, to communicate with other healthcare providers, as needed, and for data entry, billing and storage according to the Florida Department of Health policy, to assure optimal healthcare for my child.
DO YOU WANT YOUR CHILD TO PARTICIPATE IN THE FLUMIST PROGRAM?(Check One): YES or NO

_________________________________ ______________________________ ________________
Printed Name of Parent/Guardian Signature of Parent/Guardian Date AREA FOR OFFICIAL USE ONLY FOR ADMINISTRATION

1st dose Manufacturer: MedImmune (MED)

2nd dose Manufacturer: MedImmune (MED)
1st Vaccine Lot # and Expiration Date Label 2nd Vaccine Lot # and Expiration Date Label Date Given: _________________________________________ Date Given: _________________________________________ Signature/Title _______________________________________ Signature/Title _______________________________________ Nurse’s Notes (Include your name, date & title): School Nurse Initial

Source: http://www.levy.k12.fl.us/health/2013Mistconsent.pdf

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