Form Pc-809-3 - Off-Site Influenza And/or Mmr Vaccine Documentation/consent Form printable pdf download

-S

MMR V

ITE

NFLUENZA AND

ACCINE

OCUMENTATION

ONSENT

ORM

Name:

__________________________________________________________________________________________________________________________________

)

LEASE

RINT

AST

IRST

KU Student ID#: _____________________________ Date of Birth: ______________ Gender at Birth:  Male

 Female

MM/DD/YYYY

Address: __________________________________________________________________________________________

Street Address

City

State

Zip

Phone Number:  Mobile  Home  Work ____________________________________________________________

I have been offered a copy of the Vaccine Information Statement(s) (VIS) checked below. I have read, had explained to me, and

understand the information in the VIS(s). I ask that the vaccine(s) checked below be given to me.

 MMR

 Influenza, Inactivated

 Influenza, Live

MMUNIZATION

CREENING

UESTIONNAIRE

1. Are you currently sick or experiencing a high fever?

 Yes

 No

2. Do you have allergies to latex, medications, food or any vaccine?

 Yes

 No

3. Have you had a serious reaction to a vaccine in the past?

 Yes

 No

4. Do you have a history of Guillain-Barre’ Syndrome?

 Yes

 No

5. Do you have any medical problems (cancer, leukemia, AIDS, etc.) that make it hard

 Yes

 No

for you to fight infection?

6. Are you taking cortisone, prednisone, other steroids, or anti-cancer drugs, or

 Yes

 No

immunosuppressants, or had radiation treatments, or antiviral drugs?

7. Have you received blood, plasma, or immune globulin in the past twelve months?

 Yes

 No

8. Are you pregnant or planning to becoming pregnant within the next four weeks?

 Yes

 No

9. Have you received vaccinations in the past 4 weeks?

 Yes

 No

10. Are you at least 18 years of age?

 Yes

 No

_________________________________________

_______________________

Signature of Patient or Parent/Guardian

Date

***************************

NTERNAL

NLY

Site ________ Lot# _______ Exp __________ Signature ___________________________ VIS given to pt______________

(Date Published)

Site ________ Lot # ______ Exp __________ Signature ____________________________ VIS given to pt _____________

(Date Published)

 R&R

 Nursing

 BO

PC-809-3

ATKINS

EALTH

ERVICES

09-17-15

NIVERSITY OF

ANSAS

Form Pc-809-3 - Off-Site Influenza And/or Mmr Vaccine Documentation/consent Form

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