VACCINE ADMINISTRATION RECORD FOR SCHOOL IMMUNIZATION OUTREACH

Pembina County Public Health (Provider #29) 301 Dakota Street West #2 Cavalier, ND 58220701-265-4248

Information collected on this form will be used to document authorization of receipt of vaccine(s) and will be shared through the North Dakota Immunization Information System (NDIIS) with other entities in accordance with North Dakota Century Code 23-01-05.3.

Child’s Name (Last, First, MI): / Birthdate: / Age: / Sex:
M F
Address: / City: / State: / Zip Code: / County:
Parent/Guardian Name: / Daytime Contact #:
Insurance Company (Attach proof of insurance):
Policy Number/Medicaid ID Number:
Policy Holder’s Name (Last, First, MI): / Policy Holder’s Relationship to Patient:
Policy Holder’s Date of Birth:
Policy Holder’s Phone Number:
Circle all that apply to the child:
American Indian/Alaskan Native Medicaid Eligible No Insurance Underinsured Private Insurance

1. Is the child sick today?YesNo

2. Doesthe child have allergies to anymedications, food,or any vaccine?

Please List______YesNo

3. Has the child ever had a serious reactionafter receiving a vaccination?YesNo

4. Doesthe child have cancer, leukemia, AIDS or any other immune system problem?YesNo

5. Doesthe child take cortisone, prednisone, othersteroids, or anticancer drugs,

or had radiation treatments in the past 3 months?YesNo

6. During the past year,has the child received a bloodtransfusion or blood products

or been given a medicine called immune (gamma) globulin?YesNo

7. Is the child/teen pregnant or is there a chance she could become

pregnant during the next month? (Women only)YesNo

8. Hasthe child received any vaccinations in the past 4 weeks?YesNo

9. Does the child currently use tobacco?YesNo

10 Is the child exposed to second hand smoke?YesNo

By my signature below, I am acknowledging that the office of the Pembina County Public Health Department agrees to provide me with their Notice of Privacy Practices upon my request.

A copy of the appropriate Centers for Disease Control and Prevention Vaccine Information Statement(s) has been provided. I have read, or have had explained, the information about the disease(s) and the vaccine(s) listed. There was an opportunity to ask questions and all questions were answered satisfactorily. I believe that I understand the benefits and risks of the vaccine(s)cited, and ask that the vaccine(s) listed be given to the person named above (for whom I am authorized to make this request).

I authorize the release of any medical or other information necessary to process this claim. If I am the client, or an individual legally obligated to pay for medical expenses provided to the client or a Guarantor of payment, I agree to pay and I am financially responsible for Pembina County Public Health Department’s established charges provided to the Client not covered by a third-party payer. I assign and authorize any third party payer/insurer to make direct payment to Pembina County Public Health Department of all benefits payable for the Client’s care.

Signature of person authorized to make the request to receive the vaccine(s) and completion of this questionnaire.

X ______Date: ______

BELOW FOR PCPH OFFICE USE ONLY.

Signature of Vaccine Administrator(s): Date:

VACCINE TO BE GIVEN / S/P / Route/Site / VIS / MFG / Lot # / Nurse Admin.
Tdap / IM L / R Deltoid / 02/24/2015 / GSK or SP
MCV4 / IM L / R Deltoid / 03/31/2016 / GSK or SP
HPV9 / IM L / R Deltoid / 12/02/2016 / MSD
Hepatitis A / IM L / R Deltoid / 07/20/2016 / GSK or MSD
Varicella / SQ L / R Arm / 03/13/2008 / MSD
Other (______)

If “Yes” to Question 9: Advised to Quit □ Yes □ No Referral for Cessation Offered □ Yes □ No