Influenza Vaccine 2014-2015 Health Screen & Permission Form
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1NPI:
INFLUENZA VACCINE
2014-2015 HEALTH SCREEN & PERMISSION FORM
_
School Name:
Full Name:
Date of Birth:
Age:
Gender:
M
F
/
/
Street Address:
Town/City:
Zip Code:
Daytime Phone:
Grade:
Teacher:
School Administrative Unit (District)
Please answer the following questions about the person named above. Comments may be written on the back of this form.
YES
NO
1) Does this person have a severe (life-threatening) allergy to eggs?
2) Has this person ever had a severe reaction to an influenza immunization in the past?
3) Has this person ever had Guillain-Barre Syndrome?
If you answered “yes” to any questions 1-3, please see your healthcare provider for flu vaccination
4) Has this person received any other vaccinations in the past 4 weeks, or is not feeling well?
If yes, Type of vaccine___________________________________ Date__________________
5) Does this person have long-term health problems, allergies, asthma or wheezing problems, or on long-
term aspirin treatment?
6) Does this person have a weakened immune system, or come in close contact with someone who has a
severely weakened immune system? Explain: ____________________________________________
7) Is this person pregnant or could this person be pregnant?
If you answered “yes” to any questions 4-7, this person cannot receive the intranasal flu vaccine
8) Is this person an American Indian or an Alaskan Native?
9) Is this person uninsured?
10) Is this person insured by MaineCare (Medicaid)?
MaineCare ID #:_______________________________________________________
\
11) Health Insurance: Name of Company: _________________________________________________________________
ID Number: _________________________________________
Group number: ________________________
Subscriber Name__________________________________________
Subscriber Date of Birth __________________
12) Doctor’s Name:_______________________________________
Phone Number:________________________
PERMISSION TO VACCINATE
I was given a copy of the 2014-2015 Influenza Vaccine Information Statements, I have read them or had them
explained to me and I understand the benefits and risks of the Influenza vaccine.
I give permission for a record of this vaccination to be entered into the ImmPact Registry.
I give permission for information to be used to bill MaineCare or private insurance for the cost of providing the vaccine
I give my consent for this person to receive the most appropriate vaccine, as determined by the clinic health care staff.
If my child refuses to receive the injection and does not have any of the conditions #4-7 listed above, you have my
permission to give the nasal flu mist.
I give permission for the flu vaccine to be given to the person named above by signing below.
X________________________________________________________________ Date:____________________
Signature of parent or guardian if person to be vaccinated is a minor or Signature of adult to be vaccinated
Printed Name of Parent/Guardian or Adult to be Vaccinated____________________________________________
FOR OFFICE USE ONLY:
Date Dose
Vaccine
Dose
Signature and Title of
Body
Lot Number
Route
VIS date
Administered
Manufacturer
Volume
Vaccinator
Site
□
IM single dose
/
/
□
IM multi dose
□
Intranasal
Maine CDC – 7/28/14
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Parent category: Medical