School Clinic Influenza Vaccine Administration Record and Consent Form

School Clinic Influenza Vaccine Administration Record and Consent Form

Child’s Name:______Date of Birth:______Age:___

Parent’s Name:______Daytime Phone:______

Address:______City:______Zip:______

Please answer the following questions: If there is any change in your child’s health history on the day of the clinic, please contact LaSalle County Health Department so we can update the information. (815-433-3366)
Does the person to be vaccinated have an allergy to eggs? Yes No
Has the person to be vaccinated ever had a serious reaction to influenza vaccine in the past? Yes No
Does the person to be vaccinated have a long-term/chronic problem with their heart, lungs, asthma, kidneys, neurologic or neuromuscular disease, liver, metabolic disease (e.g., diabetes), anemia or other blood disorder? Yes__ __No
If the person to be vaccinated is between 2-4 years, in the past 12 months, has a healthcare provider
ever told you the he/she had wheezing or asthma?______Yes No
Does the person to be vaccinated have a weakened immune system because of HIV/AIDS, Leukemia, Cancer, other diseases of the immune system or is on long term treatment with drugs such as high dose steroids, cancer or radiation treatment? Yes No
Is the person to be vaccinated receiving antiviral medications? Yes No
Is the child to be vaccinated on Aspirin therapy or Aspirin-containing therapy? Yes No
Is the child to be vaccinated pregnant or could become pregnant within the next month? Yes No
Has the child to be vaccinated ever had Guillain-Barre` Syndrome? Yes No
Does the child live with or have close contact with a person who is severely immune compromised? Yes No
Has the child to be vaccinated received any other vaccinations in the past 4 weeks? Yes No

I authorize LaSalle County Health Department to provide Influenza Vaccine to my child named on this form. I have been made aware that I can contact LCHD with any questions I have. I have also been provided the information necessary to access an Influenza Vaccine Information Statement (VIS) to read prior to the date of the clinic.

Parent/Guardian Signature:______Date:______

*Please complete:*

I have a Medical Card or All Kids Card. Please copy and attach to form.
I have private insurance which pays for Flu Shots. Please include a $25.00 payment with this form.
An insurance receipt will be provided to the child the day of the clinic.

I have private insurance or no health insurance which pays for Flu Shots. Please include a $10.00
payment with this form.

Nurses Signature______Date:______Lot#______