Influenza Vaccine Administration Form Page 4
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4Screening Checklist
patient name
for Contraindications
date of birth
/
/
month
day
year
to Inactivated Injectable Influenza Vaccination
For patients (both children and adults) to be vaccinated: The following questions will help us
determine if there is any reason we should not give you or your child inactivated injectable
influenza vaccination today. If you answer “yes” to any question, it does not necessarily mean
you (or your child) should not be vaccinated. It just means additional questions must be asked.
If a question is not clear, please ask your health care provider to explain it.
don’t
yes
no
know
1. Is the person to be vaccinated sick today?
2. Does the person to be vaccinated have an allergy to eggs
or to a component of the vaccine?
3. Has the person to be vaccinated ever had a serious reaction
to influenza vaccine in the past?
4. Has the person to be vaccinated ever had Guillain-Barré syndrome?
/
/
form completed by
date
form reviewed by
date
Technical content reviewed by the Centers for Disease Control and Prevention
651 - 647 - 9009
Saint Paul, Minnesota
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/catg.d/p4066.pdf
Item #P4066 (8/15)
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