2011-2012 Seasonal INFLUENZA (FLU) VACCINE CONSENT FORM

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PRINT NAME EMPLOYEE# DEPARTMENT

Check One: Associate Physician Volunteer Other (i.e. contractor, student, etc.)

*If you answer “YES” to any of the questions below, you may need authorization from your Physician.

Please circle the answer to the following questions:

  1. Do you have any allergies to chicken or chicken eggs Yes No
  2. Do you have any allergies to latex rubber or Thimerosal? Yes No
  3. Are you receiving ongoing medical treatment by a healthcare provider? Yes No
  4. Have you ever had a severe reaction to a flu shot or any other vaccine? Yes No
  5. Do you have any disease or take any medication that affects how your blood clots? Yes No
  6. Have you ever had any neurological diseases (i.e. Guillian Barre’ Syndrome) Yes No
  7. Do you have a fever or other symptoms of illness today? Yes No
  8. Are you currently taking any antiviral medications? Yes No

If you want the intranasal vaccine, please further answer these questions:

  1. Do you work in OICU, Oncology or the Cancer Clinic? Yes No
  2. Have you received any Live vaccines within the past 2 weeks? Yes No
  3. Are you 50 years old or older? Yes No
  4. Are you pregnant? Yes No

ACKNOWLEDGEMENT: I have read or have had explained to me the Vaccine Information Statement (VIS) about influenza and the influenza vaccine. I have had a chance to ask questions which were answered to my satisfaction. My election below is based upon my belief that I understand the benefits and risks of the influenza vaccine.

I am consenting to receive the Influenza vaccine (please check): Injection (or) Intranasal

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Date Given:
Time Given: / Vaccine:
Injectable (GSK)
or
Intranasal Spray
(MedImmune) / Lot #/Exp date: / Dose:
0.5 ml
Or
0.2 ml / Route/Site:
RD LD
or
Intranasal / Administered By
Name/Credential:

Signature Date

OR

I have already received my Seasonal Influenza vaccine for 2011-2012

from another provider on ___/___/___(Date)

(Signature) ______(Date) ______

Revised 9/8/11 DH