Form Pc-809-2 - Off-Site Influenza Vaccine Documentation/consent Form printable pdf download

-S

ITE

NFLUENZA

ACCINE

OCUMENTATION

ONSENT

ORM

Name: __________________________________________________________________________________________

)

LEASE PRINT

AST

IRST

KU Student ID# _________________________ Date of Birth: ____________________ Gender at birth:  Male  Female

MM /DD/ YYYY

Address: _________________________________________________________________________________________

TREET

DDRESS

ITY

TATE

Phone Number:  Mobile  Home  Work: __________________________________________________________

Immunization Screening Questionnaire

Are you currently sick or experiencing a high fever?

 Yes

 No

Are you allergic to latex, medications, food or any vaccine?

 Yes

 No

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

 Yes

 No

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

 Yes

 No

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

 Yes

 No

fight infection?

Are you taking cortisone, prednisone, or other steroids; anti-cancer drugs, immunosuppressant

 Yes

 No

drugs antiviral drugs; or had radiation treatments?

Are you pregnant or planning to become pregnant within the next four weeks?

 Yes

 No

Have you received vaccinations in the past four (4) weeks?

 Yes

 No

Are you at least 18 years of age?

 Yes

 No

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

information in the VIS. I give consent to be vaccinated with the influenza vaccine.

_______________________________________________________

______________________________________

Signature of Patient or Parent/Guardian

Date

***** **** * *** ** ** **** ***** ** ** * F

NTERNAL

NLY

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

 Influenza, Inactivated (injection)

 Influenza, Live (intranasal mist)

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

(Date Published)

 R&R

 Nursing

 BO

PC-809-2

ATKINS

EALTH

ERVICES

09-17-15

NIVERSITY OF

ANSAS

Form Pc-809-2 - Off-Site Influenza Vaccine Documentation/consent Form

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