2009 h1n1 influenza vaccine consent form

2009 H1N1 Influenza Vaccine Consent Form Information about Child to Receive Vaccine (please print)
STUDENT’S NAME (Last)
STUDENT’S DATE OF BIRTH
month_________ day________ year __________
PARENT/LEGAL GUARDIAN’S NAME (Last)
STUDENT’S AGE
STUDENT’S GENDER
PARENT/GUARDIAN DAYTIME PHONE NUMBER:
SCHOOL NAME

Screening for Vaccine Eligibility
If your child has already received a dose of the 2009 H1N1 influenza vaccine, please tell us the dates and type of vaccination.
Date received: month ____day____year_______
Date received: month ____day____year_______
The following questions will help us to know if your child can get the 2009 H1N1 influenza vaccine. Please mark YES or NO for each
question.
If you answer “NO” to all four of the following questions, your child can probably get the influenza vaccine. If you answer “YES” to
one or more of the following four questions, you must obtain the vaccine from your doctor.
1. Does your child have a serious allergy to eggs? 2. Does your child have any other 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
B. There are two kinds of 2009 H1N1 influenza vaccine, the nasal spray and the shot or injection.
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 received any vaccines (not just flu) in the past month? If yes, please list the vaccines on the next line. Vaccine: ___________________________________ Date given: month______day_______year___________ 2. Does your child have any of the following chronic health conditions such as: asthma (active wheezing), diabetes, or disease of the lungs, heart, kidneys, liver, neuro-muscular (such as seizures, cerebral palsy, etc.), or blood (such as sickle cell anemia) 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 those 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)?
If you have further questions regarding the 2009 H1N1 or season influenza vaccines please call 1-866-278-7134.

CONSENT FOR CHILD’S VACCINATION AND RELEASE OF VACCINATION INFORMATION:
I have read or had explained to me the information contained in the 2009-2010 Vaccine Information Statement for the 2009
H1N1 influenza vaccines and understand the risks and benefits of the vaccine. I have had a chance to ask questions which
have been answered to my satisfaction. I understand the benefits and risks of the H1N1 and seasonal flu vaccines and request
that my child receive the correct number of doses of H1N1 flu vaccine and/or the seasonal flu vaccine.
I authorize disclosure of this vaccination information to the school named above, public health officials, and other health care
professionals. I understand that this vaccination will be recorded in the Oklahoma State Immunization Information System
(OSIIS) for the purposes of sharing vaccination information with other health care providers and tracking vaccine inventory only.
Signature of Parent/Guardian

Source: http://web.norman.k12.ok.us/710/2009%20H1N1%20Influenza%20Mist%20Vaccine%20Consent%20Form%20(2).pdf