IM or intranasal form
2009 H1N1 Influenza Vaccine Consent Form
Section 1: Information about Child to Receive Vaccine (please print)
STUDENT’S NAME (Last) (First) (M.I.) STUDENT’S DATE OF BIRTH
month_________ day________ year __________ PARENT/LEGAL GUARDIAN’S NAME (Last) (First) (M.I.) STUDENT’S AGE STUDENT’S GENDER
M / F ADDRESS PARENT/GUARDIAN DAYTIME PHONE NUMBER:
CITY STATE ZIP
SCHOOL NAME GRADE
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_______ Form (please circle): nasal spray shot
Dose 2 Date received: month ____day____year_______ Form (please circle): nasal spray shot
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 to discuss your options.
YES NO 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 flu vaccine?
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.
YES NO 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
5. Is your child pregnant? 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
bone marrow transplant)?
Section 3: Consent
CONSENT FOR CHILD’S VACCINATION:
I have read or had explained to me the 2009-2010 Vaccine Information Statement for the 2009 H1N1 influenza vaccine and understand the risks and benefits. I GIVE CONSENT to the STATE/LOCAL health department and its staff I DO NOT GIVE CONSENT to the STATE/LOCAL health department and its for my child named at the top of this form to be vaccinated with this vaccine. staff for my child named at the top of this form to be vaccinated 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 ________________________________ Signature of Parent/Legal Guardian_____________________________________ Date: month______day______year___________ Date: month______day______year___________
Section 4: Permission to Release Information
Placeholder for parental consent for release of data from vaccination record.
Section 5: Vaccination Record FOR ADMINISTRATIVE USE ONLY
Vaccine Date Dose Route Dose Number Vaccine Lot Number Name and Title of Vaccine Administrator Administered (1st or 2nd) Manufacturer IM 2009 H1N1 / / Intranasal IM 2009 H1N1 / /