2014 Vaccine Documentation/consent Form
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1
2VACCINE DOCUMENTATION/CONSENT FORM
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 or to the person named below for whom
I am authorized to make this request. I consent to inclusion of this immunization data in the Kansas Immunization Registry for myself or
on behalf of the person named below.
DT
DTaP
Tdap
Td
HepA
HepB
Hib
HPV
Influenza
Meningococcal
MMR
PCV13
PPV23
Polio/IPV
Rotavirus
Varicella
Other_
Signature of Patient or Parent/Guardian
Date
PATIENT INFORMATION
Patient’s First Name:
Patient’s Last Name:
Phone Number:
Age:
Birth date:
Street Address:
City:
County:
State:
Zip Code:
Race: (Select one or more.)
Ethnicity:
Hispanic or Latino
AS-Asian/Pacific Islander/Other
HA-Hawaiian
Yes
No
BL-Black or African American
IN-Native American/Alaska Native
CA-Caucasian/Mexican/Puerto Rican
JA-Japanese
Gender
CH-Chinese
NW-Other Non-White
Male
Female
FI-Filipino
UN-Unknown
Primary Care Physician:
Street Address:
State:
Phone:
City:
Zip:
Fax:
PATIENT ELIGIBILITY
T19-MED
No health insurance
Native Am/Alaska Native
Underinsured*
Underserved**
T21-SCHIP
Fully Insured
*Underinsured children: insurance does not cover immunizations. Eligible through VFC program if vaccinated at a FQHC, RHC or delegated county health department.
**Underserved (State) children: Are not VFC eligible. May only be vaccinated with KIP vaccines needed at school (K-12) entry at a county health department if enrolled in
federal free or reduced-price school lunch program.
IMMUNIZATION SCREENING QUESTIONNAIRE
1. Is the patient to be vaccinated currently sick or experiencing a high fever?
yes
no
2. Does the patient have allergies to medications, food, a vaccine component, or latex?
yes
no
3. Has the patient had a serious reaction to a vaccine in the past?
yes
no
4. Has the patient had a health problem with lung, heart, kidney or metabolic disease
yes
no
(e.g., diabetes), asthma, or a blood disorder? Is he/she on long-term aspirin therapy?
5. If the patient to be vaccinated is between the ages of 2 and 4 years, has a healthcare provider told you that the
yes
no
child had wheezing or asthma in the past 12 months?
6. If the patient is a baby, have you ever been told he or she has had intussusceptions?
yes
no
7. Has the patient, a sibling, or a parent had a seizure; has the child had brain or other nervous system problems?
yes
no
8. Does the patient have cancer, leukemia, HIV/AIDS, or any other immune system problem
yes
no
9. In the past 3 months, has the patient taken medications that weaken their immune system, such as cortisone,
yes
no
prednisone, other steroids, or anticancer drugs, or had radiation treatments?
10. In the past year, has the patient received a transfusion of blood or blood products,
yes
no
or been given immune (gamma) globulin or an antiviral drug?
11. Is the patient pregnant or is there a chance she could become pregnant during
yes
no
the next month?
12. Has the patient received vaccinations in the past 4 weeks?
yes
no
IMM-51
Kansas Immunization Program
Rev. 05/09/14
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