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Student 2009-2010 pandemic h1n1 ("swine flu") vaccination consent formAnnual Influenza Vaccine Consent Form-FLU SHOT and NASAL SPRAY
Section 1: Information about Child to Receive Vaccine (please print) Fill out one form for EACH child receiving vaccine.
STUDENT’S NAME (Last)
STUDENT’S DATE OF BIRTH
month_________ day________ year __________
PARENT/LEGAL GUARDIAN’S NAME (Last)
PARENT/GUARDIAN DAYTIME PHONE NUMBER:
Section 2: Screening for Vaccine Eligibility Please mark YES or NO for each question.
Has your child been vaccinated with the seasonal influenza vaccine after July 1, 2010? YES NO The following four questions will help us to know if your child can get the intranasal influenza vaccine. If you
answer “NO” to all of them, your child can probably get the influenza vaccine. If you answer “YES” to one or
more of the following questions, your child may be able to get the seasonal influenza vaccine, but we will contact
you to discuss your options.
1. Does your child have a serious allergy to eggs? 2. Does your child have any other serious allergies? Please list: _________________________________________________ 3. Has your child ever had a serious reaction to a previous dose of flu vaccine? 4. Has your child ever had Guillain-Barré Syndrome (a type of temporary severe muscle weakness) within 6 weeks after receiving a flu vaccine?
There are two kinds of seasonal influenza vaccine. Your answers to the following questions will help us know which of the two
kinds of vaccine your child can get.
1. Has your child gotten vaccinated with any vaccine (not just flu) within the past 30 days?
Vaccine: ___________________________________ Date given: month______day_______year___________ 2. Does your child have any of the following: asthma, diabetes (or other type of metabolic disease), or disease of the lungs, heart, kidneys, liver, nerves, or blood? 3. Is your child on long-term aspirin or aspirin-containing therapy (for example, does your child take aspirin every day)? 4. Does your child have a weak immune system (for example, from HIV, cancer, or medications such as steroids or 6. Does your child have close contact with a person who needs care in a protected environment (for example, 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 2010-2011 Vaccine Information Statement (VIS) for the seasonal flu shot and nasal spray influenza
vaccine and understand the risks and benefits. (See other side of form for directions on options for reading/receiving the VIS statement)
I GIVE CONSENT to Wadena County Public Health for my child named at the top of this form to be vaccinated with this vaccine.
(If this consent form is not signed, then your child will not be vaccinated)
Signature of Parent/Legal Guardian ________________________________________________________ Date: month______day______year___________
FOR ADMINISTRATIVE USE ONLY
Name and Title of Vaccine Administrator
Insurance No Fee Donation Specify Amount: __________________________ Tracking Initials: ______entered _______billed Document in SP InFLUenza folder, Flu Admin Sheet SLV 2010 From: Menahga School and Wadena County Public Health Flu (Influenza) School Located Vaccination Clinic This year flu vaccination is recommended for all ages 6 months and older. Public Health is able to offer flu vaccine at school located vaccination clinics supported by the Minnesota Department of Health, including flu vaccine available to your student at low or no cost. If your child has not yet been vaccinated, please take advantage of this opportunity. We are offering times during the school day; and after school if you prefer to come with your child. Date/times/locations during the school day:
Monday, November 15th
If you want your child to have their flu vaccine during the school day, you will need to send this form with the back side completed and signed. Please read the Vaccine Information Statement prior to signing the form. There are 2 versions: flu shot and nasal spray. These are available: on the school website at, by paper copy you can pick up at school, or by calling the school health office at 564-4141 to have a copy mailed or sent home with your student. Please return this form to the school by Friday, November 12th if possible if you want your child to get the flu
vaccine during the school day.
Date/times/locations after school when parents can accompany their student if they prefer to be present:
Monday, November 15th from 3pm-4:30pm, for room location look for signs or check the website
If you are coming with your child after school hours, please bring this form along with you. We will have copies of the Vaccine Information Statements for you to read at the clinic. Preschool children are also welcome. We have supplies of both the flu shot and nasal spray vaccine available. Healthy children can receive either one, and children with certain health risks must receive the flu shot. If your child is healthy and you have a preference, please let your child know or indicate that here: Prefer nasal spray if my child/student is considered healthy and can receive the nasal spray Prefer the flu shot for my child/student Do not have a preference, child/student can choose based on nurse recommendation There is no charge for the vaccine. To help cover nursing time and costs, we are able to bill insurance for those costs ($13.25) if you have health insurance with vaccine coverage or we can accept donations. Please indicate below your preference: I am providing a donation in the amount of $____________ (not to exceed $13.25) Checks to WCPH You may bill our insurance for the $13.25 administration fee. (If they do not pay, you will not be billed). Thank you. If you have questions, please call Janet Mattson, School Nurse at 564-4141, ask for health office; or Cindy Pederson, Public Health Nurse at 631-7629 or 1-888-883-0351. Children age 8 and younger may need 2 flu vaccines this flu season depending on what they have received past years.
If this child is 8 or younger, we will send you a reminder if they need a second vaccine, to be given at least 4 weeks after the first.
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