Flu Vaccination Consent Form - Oxford Health Nhs Foundation Trust
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1Primary School - Seasonal Flu
Oxford Health
Vaccination Consent Form
NHS Foundation Trust
Please complete using a ballpoint pen AND RETURN TO SCHOOL AS SOON AS POSSIBLE
Child's Surname
Child's First Name
Date of Birth
Male/Female
Home Address
Daytime telephone contact
Postcode:
GP practice and address
NHS Number
(found in child’s ‘Red Book’)
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School
Year Group: Year 1
Year 2
Year 3
Severe Allergies
Medical Conditions
Regular Medication
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Has your child been diagnosed with asthma?
Yes
No
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Has your child needed to take oral steroid tablets in the last year?
Yes
No
Please enter the name of the inhaler(s), the dose and number of puffs per day
Name of inhaler
Dose
Frequency
Please ensure you notify the school nurse team and school office - before the day of vaccination if your child:
Has had steroid tablets or needed to increase the use of inhaled steroids in the 2 weeks prior to the vaccination session
Has been wheezy in the 3 days before the date of the
vaccination
session in school
as the school nurse team will be unable to vaccinate your child with the nasal vaccine in school.
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Does your child have a severe egg allergy, requiring hospital treatment?
Yes
No
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Is your child receiving salicylate (Aspirin) therapy?
Yes
No
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Is your child receiving treatment that severely affects their immune system?
Yes
No
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Is anyone in your family receiving treatment that severely affects their immune system?
Yes
No
If yes, please give details:
NB: The nasal flu vaccine contains products derived from pigs (porcine gelatine). There is no suitable alternative flu
vaccine available for otherwise healthy children. For more information on the flu vaccination programme, go to
Consent by parent/guardian with parental responsibility
I consent for my child to receive the flu
vacc
ination
YES
NO
Name
_______________________________
Signature__________________________ Date:____/____/____
(print)
(Parent/Guardian)
Reason consent refused
(PTO for additional space)
For Office Use Only
Form triaged - is child eligible for nasal vaccination?
Yes
No (reason)
Assessor (print and sign)
Date
On the day: Has the parent/child reported wheeziness
Yes (reason)
No
Assessor (print and sign)
Date
in last 3 days/or use of oral steroids/or increased use of
inhaled steroids in the past 2 weeks?
Batch No/
Place of
Date
Time
Name of nasal Vaccine
Immuniser (print and sign)
Expiry Date
administration
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