H1n1 Influenza Vaccine (Shot) Consent/declination Form
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1H1N1 INFLUENZA VACCINE (SHOT) CONSENT/DECLINATION FORM
The H1N1 influenza vaccine is offered free of charge as a benefit to all employees, volunteers and students who qualify for
vaccination based on CDC/APIC recommendations about who should get vaccinated this flu season. Please read all information on
this form, complete all questions below, and check all that applies to you personally.
Name:
DOB:
Unit assigned
School Name
Program
Instructor/Preceptor
H1N1 Vaccine
Given opportunity to read Vaccine Information Sheet (VIS) for H1N1Influenza Inactivated Vaccine
Yes
No
(8/26/09)
1. Are you allergic to eggs or egg products?
2. Are you allergic to thimerosal (a preservative)?
3. Have you ever had an anaphylactic reaction to seasonal influenza vaccine (severe low BP or
difficulty breathing)?
4. Have you ever had Guillain-Barré Syndrome within 6 weeks of taking the flu shot?
5. I am ill today and have a fever.
If you have had recent chemotherapy, radiation, or steroids (except inhaled), these conditions may decrease the effectiveness of the
vaccine. However, flu vaccination is still encouraged. A H1N1 Flu shot is recommended for any woman who will be breastfeeding or
pregnant during the influenza season. Vaccination can occur in any trimester.
I have had a H1N1 flu vaccine already this year. (Documentation required)
H1N1 flu vaccine was given by my primary care physician (Documentation required)
H1N1 flu vaccine was given at a local clinic. (Documentation required)
Date vaccinated _______________Provider/Facility_____________________________________________________
No, I do not wish to have the H1N1 influenza vaccine given to me.
I realize I am eligible for the flu shot and that my refusal of it, when offered, may put patients, visitors, and family, with
whom I have contact, at risk. By declining the flu vaccine, I realize that if I provide direct patient care within six feet of
patients, I will have to wear a mask during the flu season. I understand that non-compliance with receiving the vaccine,
refusal of wearing a mask or refusal to sign a declination will result in immediate exclusion of student or faculty member
.
from the facility
Please indicate a reason for declining the vaccine
Fear of side effects (sore arm, tenderness)
Fear of getting influenza from the vaccine
Fear of injections
Religious beliefs
Personal Choice
Permanent contra-indications as listed above (#1-4)
Other, specify _____________________
I understand that refusal to receive the H1N1 vaccine or to wear a mask will result in:
•
Immediate
from the facility for
exclusion
two weeks.
•
If after two weeks, I still refuse to comply with either masking or receiving the H1N1 vaccine I will be excluded
from the facility for the duration of the flu season.
Student Signature___________________________________________ Date:__________________________________
Official Use:
H1N1 Flu Vaccine #1
Manufacturer:
Lot Number:
Dose 0.5ml
Injection site:
L deltoid
R deltoid
RN/LPN Signature ______________________________
Date: _________________
Rev. Date: 10/05/2009
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Parent category: Medical