Seasonal Influenza Vaccine Consent Form at a glance
What it is: Seasonal Influenza Vaccine Consent Form: the person receiving the vaccine, or a parent or guardian, completes sections 1 to 3. Mark each screening answer with an X. The clinic or pharmacy completes section 4.
Who signs: The person receiving the vaccine, or parent or guardian, enters Printed name, Signature and Date.
A filled-in Seasonal Influenza Vaccine Consent Form example: a school employee gets a flu shot
How to fill out Seasonal Influenza Vaccine Consent Form, box by box
Person receiving the vaccine
In 1. Person receiving the vaccine, enter Last name, First name, Middle name, Date of birth (MM/DD/YYYY), Age and Sex.
Enter Street address, City, State, ZIP code, Telephone and Email.
Vaccine is for
Vaccine is for: Employee, Student, Physician, Licensed health care provider, Contractor, Volunteer or Patient or member of the public.
Enter Facility or work site, Company or organization, Employee or student ID, Health insurance plan and Member ID.
Emergency contact and primary care provider
Enter Emergency contact, Emergency contact telephone and Primary care provider.
Screening answers
2. Health screening has Screening answers: Screening question, Yes, No and Not sure.
Feeling sick today, or a fever; Serious reaction to a flu vaccine in the past; Severe allergy to a vaccine ingredient, eggs, latex or a preservative; Guillain-Barre syndrome or a lasting neurological illness.
Pregnant now; Weakened immune system from an illness or a treatment; Long-term heart, lung, kidney or metabolic illness, or asthma.
Any other vaccine in the past four weeks; Flu vaccine already received this season; Fainting or dizziness after a past injection.
Details of any Yes or Not sure answer
Enter Details of any Yes or Not sure answer.
Signature
In 3. Signature, enter Relationship to the person receiving the vaccine (if not self).
Clinic or pharmacy use only
4. Clinic or pharmacy use only has Clinic or pharmacy, Telephone and Vaccinator credentials.
It also has Vaccine information statement edition (MM/DD/YYYY), Date statement given (MM/DD/YYYY), Dose given (mL), Vaccine product, Manufacturer, Lot number, Expiration date (MM/DD/YYYY) and NDC.
Route: Intramuscular, Intranasal, Intradermal, Jet injector or Other. Site: Left deltoid, Right deltoid, Left thigh, Right thigh, Nostrils or Other.
Enter Date given (MM/DD/YYYY), Time given and Dose number this season. Reported to the immunization registry: Yes, No or Not applicable.
Outcome: Given, no reaction seen, Reaction seen, see notes or Deferred or declined. Enter Clinical notes.
"I certify that the entries above are complete and correct." Person giving the vaccine: Printed name, Signature and Date.
Sources
[1] Seasonal Influenza Vaccine Consent Form (the served file; no issuer file found) (the Official source link on this page).
