School based clinic IM or intranasal form
2009 H1N1 Influenza Vaccine Consent Form 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 M / F PARENT/GUARDIAN DAYTIME PHONE Child's Doctor: SCHOOL NAME
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 your child can get the 2009 H1N1 influenza vaccine. Please mark YES or NO for each question.
A. If you answer “NO” to all four of the following questions, your child can probably get the influenza vaccine. If you answer “YES” to one or more of the following four questions, your child may be able to get the 2009 H1N1 vaccine, but we will contact you if there is a concern.
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 after receiving a
B. There are two kinds of 2009 H1N1 influenza vaccine. Your answers to the following questions will help us know which of the two kinds of vaccine your child can get. There is injectable (shot in the arm) and intranasal (a spray in the nose) forms of H1N1 influenza vaccine.
1. Has your child gotten vaccinated with any vaccine (not just flu) within the past 30 days?
Vaccine: ___________________________________ Date given: month______day_______year___________ 2. Does your child have any of the following: 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
6. Does your child have close contact with a person who needs care in a protected environment (for example, someone who has recently
7. I would like my child to get the injectable (shot) form of the flu vaccine.
8. I would like my child to the intranasal (spray in the nose) form of the flu vaccine.
Your child will only receive the intranasal flu vaccine if you answered no to all of the questions in section B. (Exception: The only vaccines that cannot be given within 4 weeks of the H1N1 intranasal influenza vaccine are: the intranasal seasonal 2009 influenza vaccine, MMR or Varicella ) Section 3: Consent CONSENT FOR CHILD'S VACCINATION: I have received and read the 2009-2010 Vaccine Information Statement for the Inactivated and/or Live Intranasal 2009 H1N1 InfluenzaVaccine or have had the information explained to me. I have had a chance to ask questions, which were answered to my satisfaction. I believe I understand the benefits and risks of H1N1 influenza vaccine. I give consent to Genesis VNA/Clinton County Health Department and it's staff for my child named at the top of this form to be vaccinated with this vaccine. I accept responsibility for seeking medical attention for any problems with this vaccine. (If this consent form is not signed, dated and returned, then your child will not be vaccinated at school.) Signature of Parent/Legal Guardian_______________________________________________________ Date: month_______ day______ year________
Section 4: Vaccination Record FOR ADMINISTRATIVE USE ONLY Date Dose Dose Number Lot Number Name and Title of Vaccine Administrator Administered (1st or 2nd) Manufacturer
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