2015-2016 Inactivated Injectable Influenza Consent Form printable pdf download

2015-2016 INACTIVATED INJECTABLE INFLUENZA CONSENT FORM

Information about person to be vaccinated (please print)

for office use only

Last Name:__________________________________________

Age: _________

Child needs second dose

First Name: _______________________________

Sex: ___M ___F

Assess if child needs second dose

Date of Birth:____________________

Phone #

__________________

Clinic :

Address

City ____________________________________

Zip __________

For child - Please Print

Parent's Name:______________________________________________

For child being vaccinated at school based clinic

Grade _____

School ________________________________________

The South Dakota Immunization Information System (SDIIS) is an automated system to document vaccinations given in South Dakota. SDIIS will give

parents access to their child's immunization record from any participating South Dakota provider. SDIIS also allows providers to send reminder notices

regarding needed immunizations. Health care providers, health care facilities, federal or state agencies, welfare agencies, school or family day care

facilities may have access to this information in accordance with applicable HIPAA Privacy Act standards and requirements*. Immunization records

remain confidential, and any person who fails to protect the information is guilty of a Class 1 misdemeanor. If you choose NOT to have you/your child's

immunization record shared with other providers, you may request a refusal form.

For a child being vaccinated - check any that apply

(Check here if none apply) ________

Enrolled in Medicaid

Please provide Medicaid #

American Indian or Alaskan Native

Does not have health insurance

Health insurance that DOES NOT pay for vaccines

Please answer the following questions for the person to be vaccinated.

Yes

Don't Know

1) Is the person sick today?

2) Does the person have an allergy to eggs or to a component of the vaccine?

3) Has the person ever had a serious reaction to influenza vaccine in the past?

4) Has the person ever had Guillain-Barré syndrome?

I have been provided a copy of and have read or have had explained to me the information about influenza and the vaccine listed below.

I have had a chance to ask questions that were answered to my satisfaction. I believe I understand the benefits and risks of the vaccine

and ask that the vaccine be given to me or the person named above for whom I am authorized to make this request.

Signature

Date

(Parent or guardian if minor)

For child being vaccinated at a school based clinic

If you are completing this form for a child to be vaccinated at school and you will not be accompanying him/her,

please provide a phone number where you can be reached on the day of the clinic

(phone)

for office use only

Date/Time

Vaccine Manufacturer

Vaccine

Site

Signature of person

Type

Route

Date of VIS

(Circle)

Lot number

(Circle)

Publication

administering vaccine

SanofiPasteur

IIV4

---------------

Deltoid

08/07/15

GlaxoSmithKline

Thigh

Abbreviation Key: IIV4 - Inactivated Influenza Vaccine, Quadravalent

IM - Intramuscular

L - Left

R - Right

* If you would like to review the Notice of Privacy Practices, Version I dated 04/14/2003 from the South Dakota Department of Health please refer to

website:

Revised 8/25/15

2015-2016 Inactivated Injectable Influenza Consent Form

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