2011 Vaccine Documentation/consent Form printable pdf download

VACCINE DOCUMENTATION/CONSENT FORM

I have been offered a copy of the Vaccine Information Statement(s) (VIS) checked below. I have read, had explained to me, and

understand the information in the VIS(s). I ask that the vaccine(s) checked below be given to me or to the person named below for whom

I am authorized to make this request. I consent to inclusion of this immunization data in the Kansas Immunization Registry for myself or

on behalf of the person named below.

DTaP

Tdap

HepA

HepB

Hib

HPV

Influenza

Meningococcal

MMR

PCV7/13

PPV23

Polio/IPV

Rotavirus

Varicella

Other_____________

___________________________________________________________

_______________

Signature of Patient or Parent/Guardian

Date

PATIENT INFORMATION

Patient’s Last Name:

Patient’s First Name:

Phone Number:

Age:

Birth date:

Street Address:

City:

County:

State:

Zip Code:

Race: (Select one or more.)

Ethnicity:

Hispanic or Latino

___ AS-Asian/Pacific Islander/Other

___ HA-Hawaiian

___ Yes

___ No

___ BL-Black or African American

___ IN-Native American/Alaska Native

___ CA-Caucasian/Mexican/Puerto Rican

___ JA-Japanese

Gender

___ CH-Chinese

___ NW-Other Non-White

___ Male

___ Female

___ FI-Filipino

___ UN-Unknown

Primary Care Physician:

Street Address:

State:

Phone:

City:

Zip:

Fax:

PATIENT ELIGIBILITY

Medicaid

No health insurance

Native Am/Alaska Native

Underinsured*^

Underserved**^

HealthWave

Fully Insured

*Underinsured children: insurance does not cover immunizations. Eligible through VFC program if vaccinated at a FQHC, RHC or county health department.

**Underserved children: Are not VFC eligible. May only be vaccinated with KIP vaccines needed at school entry at a county health department if enrolled in federal

free or reduced-price school lunch program.

IMMUNIZATION SCREENING QUESTIONNAIRE

__yes __no

1. Is the person to be vaccinated currently sick or experiencing a high fever?

__yes __no

2. Has the person to be vaccinated had a serious reaction to a vaccine in the past?

__yes __no

3. Does the person to be vaccinated have any allergies that produce a severe (anaphylactic) reaction?

__yes __no

4. Has the person to be vaccinated had a seizure or other neurological problem?

__yes __no

5. Does the person to be vaccinated have any medical problems that make it hard for him/her to fight infection?

__yes __no

6. Does the person to be vaccinated have close, regular contact with someone with a weakened immune system?

__yes __no

7. Is the person taking cortisone, prednisone, other steroids, or anti-cancer drugs, or had x-ray treatments?

__yes __no

8. Has the person to be vaccinated received blood, plasma, or immune globulin in the past twelve months?

__yes __no

9. Is the person to be vaccinated pregnant or thinking of becoming pregnant within the next three months?

IMM-51

Kansas Immunization Program

Rev. 05/24/11

2011 Vaccine Documentation/consent Form

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