Shot Consent Form - Kanawha-Charleston Health Department
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2KANAWHA-CHARLESTON HEALTH DEPARTMENT
108 Lee Street, East, Charleston WV 25301
2015 – 2016 Seasonal Influenza Vaccine
SHOT CONSENT FORM
Student’s Name ___________________________________________________________________________________
(Last)
(First)
(Middle)
Current Address __________________________________________________________________________________
(Street Address)
(City)
(State)
(Zip)
Parent/Guardian Phone #s: Home __________________ Cell __________________Work __________________
Date of Birth _______________ Age _____
Gender M / F
Race _____________ Last 4 digits SS#_________
Month//Day/Year
(optional)
School Name____________________________ Grade________
Teacher/Homeroom_______________________
FLU SHOT SCREENING FORM
Please review the Vaccine Information Sheet BEFORE completing this form. On the day of the vaccination clinic, If the
child is ill with a fever, the nurse may decide to postpone the vaccination. Form must be completed by a parent or legal
guardian.
YES NO
1. Has your child ever received a Seasonal or H1N1 flu vaccine before?
a. If YES, has your child received the shot____ or intranasal____ or both ______
b. If NO, your child has never had a flu vaccine, does he/she have any allergies?
Describe______________________________________________________________________________
2. Did your child have a reaction to an influenza vaccine before?
a. If YES, Describe____________________________________________________________________
3. Has your child ever been paralyzed with a disease called Guillain-Barré Syndrome (GBS)?
a. If YES, Describe ____________________________________________________________________
4. Does your child have a severe allergy to eggs?
a. If YES, check with your doctor to see if your child can receive the flu vaccine.
5. Does your child have an allergy to latex?
a. If YES, Describe ____________________________________________________________________
Parent or Legal Guardian_________________________________________________ Date________________
Signature
PLEASE TURN PAGE OVER AND COMPLETE THE OTHER SIDE
KCHD-SLV-3
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