Microsoft word - vaccine consent form.doc

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
PARENT/GUARDIAN DAYTIME PHONE NUMBER:
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.
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 to discuss your options.

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.
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 had a Section 3: Consent
CONSENT FOR CHILD’S VACCINATION:
I have read or had explained to me the 2009 Vaccine Information Statement for the 2009 H1N1 influenza vaccine and understand the risks and benefits. I GIVE CONSENT to the Champaign –Urbana Public Health District and its 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 _____________________________________________________________________________ Date: month______day______year___________
Section 4: Permission to Release Information
I do hereby acknowledge that I have received a copy of the “Joint Notice of Privacy Practices” from the Champaign -Urbana Public Health District (CUPHD). I
GIVE CONSENT to the Champaign-Urbana Public Health District to release a copy of this immunization record to my child’s personal physician
Dr.________________________________________________________________________ for his/her records.
Signature of Parent/Legal Guardian______________________________________________________________________________
Date: month _____day______ year___________
ADMINISTRATIVE USE ONLY
Date Dose
Dose Number
Lot Number
Exp. Date Name and Title of Vaccine Administrator
Administered
(1st or 2nd)
Manufacturer

Source: http://www.ms.k12.il.us/sites/default/files/Vaccine%20Consent%20Form-H1N1.pdf