Influenza Vaccine Child Consent Form - 2015-2016
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1Influenza Vaccine Child Consent Form 2015-2016
Section 1: Information about Child to Receive Vaccine (please print)
CHILD’S NAME (Last)
CHILD’S DATE OF BIRTH
(First)
(M.I.)
month_________ day________ year __________
PARENT/LEGAL GUARDIAN’S NAME (Last)
CHILD’S AGE
CHILD’S GENDER
(First)
(M.I.)
M
F
►Insurance/Eligibility Status—Check all that
ADDRESS
PHONE NUMBER
apply◄
Insured, Vaccines Covered
Insured, Vaccines Not Covered
CITY
STATE
ZIP
Badger Care
No Health Insurance
Medicaid Eligible
Native American
Primary Medical Provider:
Section 2: Screening for Vaccine Eligibility
The following questions will help us to know if your child can get the seasonal influenza vaccine and which kind they can receive.
Please mark YES or NO for each question.
YES
NO
1. Is your child sick today?
2. Does your child have an allergy to eggs, gentamicin, gelatin or other component of the influenza vaccine?
3. Does your child have any other serious allergies? Please list: _________________________________________________
4. Has your child ever had a serious reaction to a previous dose of flu vaccine?
5. Is your child younger than age 2 or older than 18 years of age?
6. Has your child ever had Guillain-Barré Syndrome (a type of temporary severe muscle weakness) within 6 weeks after receiving a flu
vaccine?
7. Does your child have a long-term health problem with heart disease, lung disease, asthma, kidney disease, neurologic or
neuromuscular disease, liver disease, metabolic disease (e.g. diabetes), anemia, or other blood disorder?
8. If the child to be vaccinated is a child ages 2 through 4 years in the past 12 months, has a health care provider ever told you that he or
she had wheezing or asthma.
9. Does your child have a weakened immune system because of HIV/AIDS or other disease that affects the immune system, long-term
treatment with drugs such as high-dose steroids, or cancer treatment with x-ray or drugs?
►►10. Has your child received any other vaccinations in the past 4 weeks? (e.g. MMR, Chicken Pox or nasal FLUMIST ◄◄
Vaccine: _____________________________
Date given: Month ________________ Day____________Year_________
11. Is your child currently receiving antiviral medications, Tamiflu (oseltamivir) or Relenza (zanamivir), in the past 48 hours?
12. Is your child on long-term aspirin or aspirin-containing therapy (for example, does your child take aspirin every day)?
13. (Girls only) Is your daughter pregnant or could she become pregnant within the next month?
14. Does your child live with or expect to have close contact with a person whose immune system is severely compromised and who
must be in a protective environment (such as a hospital room with reverse air flow or someone who has recently had a
bone marrow transplant)?
Section 3: Consent
CONSENT FOR CHILD’S VACCINATION:
I have read or had explained to me the 2015-2016 Vaccine Information Statement for the seasonal influenza vaccine and understand the risks and benefits.
I GIVE CONSENT to the STATE/LOCAL health department and its staff for my child named at the top of this form to be vaccinated with this vaccine and .
(If this consent form is not signed, dated, and returned, then your child will not be vaccinated at school) and entry into WIR.
Signature of Parent/Legal Guardian _____________________________________________________________ Date: ___________________________
Section 4: Vaccination Record
FOR ADMINISTRATIVE USE ONLY
Vaccine
Date Dose
Route
Site
Dose #
Vaccine
Lot Number
Administered
(1st or 2nd)
Manufacturer
Quadrivalent FluMist
FJ2099
Intranasal
MedImmune
____/____/2015
Influenza
IM
LV
RV
Sanofi Pasteur
Fluzone
UI422AB
LD
RD
Sanofi Pasteur
Fluzone, P-free
U5319DA
(Baby Baby)
Other: _______________________________
Signature and Title of
Vaccine Administrator:
SleeepyP/immuiz/InfluenzaVaccineChild 09202011 2012 2013 2014 2015
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