School Vaccine Consent Form - Renville County printable pdf download

2014 SCHOOL VACCINE CONSENT FORM

& ADMINISTATION RECORD

(Tdap, HPV & Meningococcal)

* Complete both sides of form. *

Section 1: Information to Receive Vaccine (please print)

NAME (Last)

(First)

(M.I.)

BIRTHDATE:

ADDRESS

GRADE:

CITY

STATE

ZIP

DAYTIME PHONE NUMBER:

Parent Name:

Section 2: Screening Checklist: (All questions below pertain to the person named in Section 1.)

These questions help us determine which vaccines may be given. If you answer “yes”, it does not necessarily mean your child should not be vaccinated. It

means, more questions will be asked.

YES

1. Is your child/teen moderately or severely ill today? (get vaccinated when feeling better)

2. Does your child/teen have allergies to medications, food, a vaccine component, or latex? Explain:

3. Has your child/teen had a serious reaction to a vaccine in the past?

4. Has your child/teen had a seizure? Has your child/teen had brain or other nervous system problems like Guillain-Barré Syndrome?

5. Has the child/teen received vaccinations in the past 4 weeks?

6. Is the teen pregnant or is there a chance she could become pregnant during the next month?

7. Has your child/teen received any previous doses of HPV (Gardasil) ? How many?________

Section 3: Consent

√ CHECK THE VACCINES REQUESTED

CONSENT FOR VACCINATION:

I have read or had explained to me the Vaccine Information Statements for the vaccine(s) and understand the risks and benefits.

I GIVE CONSENT to Renville County Public Health to vaccinate the child/teen named above and record in the state’s immunization registry (MIIC) for:

□

Tetanus Diphtheria acellular Pertussis (Tdap)

□

Meningococcal (MCV)

□

Human Papillovirus (HPV) I understand that this is a three dose series to be given within 6 months or a completion of a previously started series.

I attest I am the child’s parent, authorized representative, or legal guardian and may provide consent for the immunization(s). I understand This signature

serves as consent for second dose if needed.

If this consent form is not completely filled out, signed, and dated, your child will not be vaccinated

Signature of Parent:_________________________________________________ Date:______________________

Section 4: Vaccination Record: FOR ADMINISTRATIVE USE ONLY

Tdap _______

MCV ______

HPV_______

Renville County Public Health Services

Office Address: 105 S Fifth Street, Olivia, MN 56277 Phone: 320-523-2570

Tdap: Date and Nurse’s Signature

MCV: Date and Nurse’s Signature

Date on VIS: 5/9/2013