Flumist (Intranasal Flu Vaccine) Consent Form
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1FluMist (Intranasal Seasonal Flu Vaccine) Consent Form
Are you interested in having your child participate in the FluMist vaccine program at school?
Please write your child’s name on the top line and return this to the Westford
_______ NO
Health Department.
_______ YES
Please fill out the rest of this form and return it to Health Department
Student’s Name __________________________________Age:___________Grade:________________
Address:_____________________________________________City:____________________________
Parent/Guardian Name (Print Clearly)_____________________________________________________
Day time phone #___________________________Emergency phone #__________________________
Name of Primary Care Physician ______________________________________ Phone #_____________________
Has your child received a flu vaccination in a prior year?
YES
NO
Has your child received a flu vaccine already this fall of 2009?
YES
NO
If so what date__________________________________
Has your child received any live vaccines within the past month?
YES
NO
Please answer each question below which will be reviewed by a nurse prior to vaccination.
1.
Is your child allergic to eggs or egg protein?
YES
NO
2.
Is your child allergic to gentamicin, gelatin or arginine?
YES
NO
3.
Has your child ever had a life threatening reaction to flu vaccine?
YES
NO
4.
Has your child ever had Guillain-Barre syndrome?
YES
NO
5.
Is your child receiving aspirin or aspirin-containing therapy?
YES
NO
6.
Does your child have kidney, heart, lung disease or diabetes?
YES
NO
7.
Does your child have a weakened immune system?
YES
NO
8.
Does your child have Asthma (at any age), active wheezing (at any age)
or recurrent wheezing (2 –5 yrs old)?
YES
NO
9.
Will your child be around a person with a severely impaired immune system? YES
NO
10.
Is your child pregnant or nursing?
YES
NO
If you answer YES any of the above questions, we are unable to provide this vaccine to your child in this setting.
Allergies/medical alert:______________________________________________________________________
Parent/guardian request for administration of Live, Intranasal Influenza Vaccine for the above named child:
I have been given the CDC Vaccine Information Statement. I have read this document and have no further questions at this
time. I understand the risks and benefits of live intranasal influenza vaccine. My child has no allergies to egg, gentamicin,
gelatin or arginine and has not had flu vaccine this year. I request and voluntarily consent that the vaccine be given to my
child listed below, of whom I am the parent or legal guardian. I acknowledge that no guarantees have been made
concerning the vaccine’s success. I understand the side effects and warnings of the vaccine.
Signature of Parent/Guardian:________________________________________Date: _____________
___________________________________________________________________________________________________
For Clinic Use:
Vaccine Name:___________________________________ Vaccine manufacturer:_______________________________
Vaccine lot number________________________________ Date on VIS________________________________________
Administered by:_____________________________________ Date Administered: ________________________
Is a second dose recommended? ________YES
________NO
Wdv RPS 8-09
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