Patient Eligibility Screening Record
Vaccines for Children Program
Date: ______Student’s Date of Birth: _____/_____/_____ Grade: ______
Student’s Name: ______Parent/Guardian Name: ______
**Your child SHOULD NOT take the hepatitis B vaccine if they have a hypersensitivity to baker’s yeast (the kind used for making bread) or if they have had a reaction to a previous dose of the vaccine.
______No, my child has not had any reaction to Baker’s yeast
______No, my child has not had any reaction to a previous dose of Hepatitis B
Your child will qualify for vaccination through the Vaccine for Children (VCF) Program because he/she (check only one)
a) is enrolled in Medicaid or the Health Plan _____(provide copy of card)
b) does not have medical insurance _____
c) is American Indian or Alaskan Native _____
d) has health insurance that DOES NOT pay for immunizations _____
e) has health insurance with a large deductible _____
f) My child does not qualify for VCF program,
but is covered under a private insurance plan _____ (provide copy of card)
_____Yes, I want my child to receiving the Hepatitis B vaccine through the VCF program.
_____Yes, I want my child to receiving the Hepatitis B vaccine that will be covered under my private insurance plan.
______
Did your child have a reaction to their DTAP vaccine as a child? ______YES ______NO
Is your child allergy to pertussis? ______YES ______NO
_____Yes, I want my child to receiving the TDAP (tetanus, diphtheria, and pertussis) vaccine through the VCF program. If your child has had a reaction to DTAP in the past we will give them a TD (tetanus and diphtheria).
_____Yes, I want my child to receiving the TDAP (Tetanus, diphtheria, pertussis) vaccine that will be covered under my private insurance plan. If your child has had a reaction to DTAP in the past we will give them a TD (tetanus and diphtheria).
______
_____Yes, I want my child to receive the Meningitis vaccine (Menactra) through the VCF program.
_____Yes, I want my child to receive the Meningitis vaccine (Menactra) through my private insurance plan.
______
_____ Yes, I want my child to receiving the HPV (Gardasil) vaccine through the VCF program.
_____ Yes, I want my child to receiving the HPV (Gardasil) that will be covered under my private insurance plan.
_____No, I do not wish for my child to receive the immunization at this time.
______
Parent/Guardian Signature Date