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ANNUAL SCHOOL INFLUENZA (FLU) IMMUNIZATION CONSENT FORM

NASAL SPRAY AND FLU SHOT

**Required For school office use: Place sticker/stamp School Address Here

SKIIP 2015-16

If you would like the vaccine given at school, fill in this form completely and legibly, including complete insurance information and return by ____________ (date) to the school nurse

School name: ______________________________________ Grade: _______ Teacher: _______________________ Student ID#:_______________

with school address here

Student’s legal last name: ____________________________ First name: ______________________________ Middle name: ____________________

Mailing address: _____________________________________________________ Zip: __________ Daytime phone: _________________________

Birth date: _____/______/______ Age: _____ Parent/legal guardian name: ___________________________________________________________

month / day

year

first name and last name

Race:

American Indian/Native American/Alaskan Native

Asian

Other

Ethnicity:

Hispanic

Gender:

Male

Black/African American

Native Hawaiian/Pacific Islander

White

Non-Hispanic

Female

INSURANCE INFORMATION―Fill in appropriate category―REQUIRED

Centennial Care/Medicaid:

Blue Cross Blue Shield

Molina Healthcare

United Healthcare

Presbyterian

*Centennial Care (Medicaid) / Policy/Member/ID #_________________________

Private/Commercial insurance:

Blue Cross Blue Shield

Presbyterian

United Healthcare

Other insurance: ______________________

* Member ID / Patient/Policy# / Group #:______________________Responsible Party:______________________Policy Holder’s Date of Birth:___________

No health insurance

MEDICAL SCREENING QUESTIONS―REQUIRED

Questions 1-2 help to determine if your child will need one or two doses of flu vaccine

YES

1. Has your child received 2 or more doses of flu vaccine in their lifetime? (Not including H1N1-only vaccine)

☐

2. Has your child received flu vaccine this flu season (since July 1, 2015)?

☐

*If “YES”, how many doses and date(s) of vaccination: ☐ 1 Dose ☐ 2 Doses Date(s) received:

If you answer “YES” to either question below, your child cannot get vaccinated at school. Contact your child’s doctor for options.

YES

3. Does your child have a severe allergy (difficulty breathing, swollen face/lips, recurring vomiting) to eggs, or the following antibiotics: gentamicin, neomycin,

☐

or polymixin?

4. Has your child ever had a serious reaction to flu vaccine or developed Guillain-Barré Syndrome (a temporary severe muscle weakness)?

☐

There are two types of flu vaccine available. If you answer “YES” to questions 5-12 below your child may not be able to get the nasal spray (live)

YES

vaccine, but may still be able to receive a flu shot, if available. The nurse will assess eligibility based on the answers to these questions.

5. Does your child have a severe allergy to latex or the food ingredients MSG, gelatin, arginine, or any other serious allergy?

☐

Please list:

6. Has your child received any vaccines within the past 30 days? Please list:

; Dates given:

☐

7. Has your child had an asthma attack, a wheezing episode, or taken asthma medicine within the past 12 months?

☐

8. Does your child have: diabetes, diseases of the heart, liver, kidneys or lungs, seizures, blood disorder, anemia, neuromuscular disease, or cerebral palsy?

☐

9. Is your child on long-term aspirin-containing therapy, for example, does your child take aspirin every day?

☐

10. Does your child have a weakened immune system (for example, from HIV, cancer, or medicines such as steroids or those used to treat cancer)?

☐

11. Does your child have close or direct contact with someone who is in a protected environment for an extremely weakened immune system (for example,

☐

bone marrow transplant unit)?

12. Is your child pregnant?

☐

CONSENT FOR CHILD’S VACCINATION IN SCHOOL

I have read or had explained to me the 2015-16 Intranasal Influenza Vaccine Information Statement (VIS) and the 2015-16 Injectable Influenza Vaccine Information Statement and understand

the benefits and risks of influenza vaccine and consent that the influenza vaccine be given to the person above for whom I am authorized to make this request. If the person above for whom I am

authorized to make this request is less than 9 years old and it is determined that a 2

dose is needed, I also consent for a 2nd dose of vaccine to be given if offered through the school. I will

contact the school nurse to withdraw this consent if this child is immunized before the date of the school clinic or if I choose to do so. Unless I sign a statement signifying otherwise, I

allow immunization information to be entered into the New Mexico Statewide Immunization Information System (NMSIIS) and be released to other medical care providers to avoid unnecessary

vaccination or to ascertain immunization status. The DOH Privacy Policies are available at and will be given to all patients when they receive an

immunization.

Signature of parent/legal guardian: ___________________________________________________________

Date: ____________________

Print name of parent/legal guardian (print legibly in all capitals): ________________________________________________________________

r clinic

For clinic use (this section must be completed by the medical provider)

VIS date: 2015-2016

use (this section must be

Dose #1

VFC PIN# _____________ Date data entry completed ____________ Date vaccinated __________________

**Required: Date VIS given