Parent/guardiantocomplete

Studentdetails
Surname: / Firstname:
Dateofbirth: / Gender:GirlBoy / Schoolandclass:
NHSnumber(ifknown): / Hometelephone:
Parent/guardianmobile:
Homeaddress:
Postcode:
GPnameandaddress:
Hasyourchildbeendiagnosedwithasthma?
YesNo
IfYes, andyourchildiscurrentlytaking inhaledsteroids(i.e. usesapreventeror regularinhaler),pleaseenterthemedication nameanddailydose (e.g.Budesonide
100micrograms,fourpuffsperday):
IfYes, andyourchildhastakensteroid tabletsbecauseof theirasthmainthepast twoweekspleaseenterthe name, dose and length of course:
Pleaselettheimmunisationteamknowifyourchildhastoincreasehisorher
asthmamedicationafteryouhavereturned thisform. / Has your child already had a flu vaccination
since September2016?Yes*No
Does your child have a disease or treatment that severely affects their immune system?
(e.g.treatment for leukaemia)Yes*No
Isanyoneinyourfamilycurrentlyhavingtreatment thatseverelyaffectstheirimmunesystem?
(e.g. theyneedto bekeptinisolation)Yes*No
Doesyourchildhaveasevereeggallergy?
(needinghospitalcare)Yes*No
Isyourchildreceivingsalicylatetherapy?
(i.e.aspirin)Yes*No
*IfyouansweredYes toanyof theabove,pleasegivedetails:
Onthedayofvaccination,pleaselettheimmunisationteam knowifyourchildhasbeenwheezyinthepastthreedays.
NB.The nasal flu vaccine contains products derived from pigs (porcine gelatine).There is no suitable alternative flu vaccine available for otherwise healthy children. More information for parents is available from
Consent forimmunisation(please tickYESorNO)
YES,Iconsentformychildtoreceive the flu immunisation. / NO,I DO NOTconsentto my child receiving theflu immunisation.
If‘NO’pleasegivereason(s)below:
Signatureofparent/guardian
(withparentalresponsibility): / DateDD/MM/YYYY
FOR OFFICEUSEONLY
Presessioneligibilityassessmentfor live attenuated influenza vaccine LAIV
Childeligiblefor LAIVYesNo
If no, give details:
Additionalinformation:
Assessmentcompletedby
Name,designationandsignature:
Date: / Eligibilityassessmenton dayof vaccination
Hastheparent/childreportedthechildbeing wheezyoverthepastthreedays? / Yes / No
Ifthechildhasasthma,hastheparent/childreported:

•use of oral steroids in the past 14 days?Yes

•an increase in inhaled steroids since
consentform completed?Yes / No No
Childeligiblefor LAIVYes
If no, give details: / No
Vaccinedetails
Date:Time:
Administeredby
Name,designationandsignature:
Date: / Batchnumber:Exp / irydate:

1Asthmaticchildrennoteligibleonthedayof thesessiondueto deteriorationintheirasthmacontrolshouldbeofferedinactivated vaccineif theirconditiondoesn’timprovewithin72hrsto avoidadelayinvaccinatingthis‘atrisk’group.