Seasonal Influenza Vaccine Form – Fill Out and Use This PDF

The Seasonal Influenza Vaccine Form (SIV) is a quick and easy way to report season influenza activity in your county or region.

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Seasonal Influenza Vaccine Form PDF Details

Influenza, more colloquially known as the flu, is a highly contagious respiratory illness caused by the influenza virus. Each year, millions of people are infected with the flu, and thousands die from it. Seasonal flu vaccinations are available to protect individuals from becoming infected with the flu virus. In this blog post, we will discuss the different types of seasonal influenza vaccine forms available and how to get vaccinated.

You'll discover info about the type of form you need to prepare in the table. It can tell you how long it may need to finish seasonal influenza vaccine form, exactly what fields you will need to fill in, etc.

Question	Answer
Form Name	Seasonal Influenza Vaccine Form
Form Length	1 pages
Fillable?	Yes
Fillable fields	44
Avg. time to fill out	9 min 3 sec
Other names	ma consent for vaccine, influenza vaccine 2020 2021 consent form, influenza vaccine consent form, informed consent form flu vaccine

12

Form Preview Example

CONSENT FORM FOR SEASONAL INFLUENZA VACCINE

I have read or have had explained to me the information about influenza and influenza vaccine. I have had an opportunity to discuss the benefits and risks of influenza vaccine with a healthcare provider of my choice before coming here today. I have had a chance to ask questions which were answered to my satisfaction. I understand the benefits and risks of influenza vaccine and request that the vaccine be given to me.

Please print clearly: Each field is required.

Name: ________________________________________________ 3/4 ID or Last 4 SSN: _________________

(FIRST)	(MIDDLE)	(LAST)
Birthday____/____/____
Vaccine is for (circle one): Student		Physician	Licensed HCP	Contractor	Volunteer
Working in which facility?: _________________________________________________

Company/Organization: ____________________________________________________

Has the person receiving the vaccine ever had a severe allergic (hypersensitivity) reaction to eggs, chickens, or chicken feathers? ____Yes ____No

Does the person receiving the vaccine have a history of Guillain-Barré syndrome or a persistent neurological illness? ____Yes ____No

Is the person receiving the vaccine pregnant? ____Yes			____No (If yes, LAIV contraindicated, TIV recommended)
Is the person receiving the vaccine allergic to Thimerosal (Preservative found in contact lens solution), any
vaccine ingredient, or latex? ____Yes	____No
X________________________________________________________________ ______________________
Signature of person receiving vaccine					Date


DO NOT WRITE IN THIS SPACE—OFFICE USE ONLY			VIS Edition Provided: ________________
Lot number: ________________________Expiration Date: ____________________
CHECK ONE:
___ 0.5 mL IM Influenza Virus Vaccine given in ___left			___right deltoid – TIV or QIV
___ 0.5 mL IM Influenza HIGH Dose Virus Vaccine given in				___left ___right deltoid (65+) TIV-SR
___ 0.2 mL Live Attenuated Influenza Virus Vaccine given intranasally (half each nostril) – TRI or QUAD
___ 0.5mL Intradermal Virus Vaccine	site ________________________ - TIV
___ 0.5mL FluBlok Influenza Virus Vaccine given in ___left				___right deltoid
___ Children 6-35 months: 0.25 mL/dose given in ___left				___right deltoid (1 or 2 doses per season)
___ Children 3-8 years: 0.5 mL/dose given in ___left		___right deltoid (1 or 2 doses per season)
___ Children older than 9 years: 0.5 mL/dose given in		___left ___right			deltoid (1 dose per season)
_________________________________________________________					__________________	_________
Nurse/ Provider’s Signature					Date	Time

How to Edit Seasonal Influenza Vaccine Form Online for Free

The whole process of completing the consent form and cdc pre vaccination form is very effortless. Our team ensured our PDF editor is not difficult to work with and helps fill in any sort of form within minutes. Listed below are some of the steps you will need to take:

Step 1: Press the orange button "Get Form Here" on this web page.

Step 2: Right now, it is possible to edit your consent form and cdc pre vaccination form. This multifunctional toolbar makes it possible to include, eliminate, modify, highlight, and perform many other commands to the text and fields within the document.

The following areas will frame the PDF document that you will be completing:

example of blanks in nursing note for influenza vaccine

In the Date area, put in writing your data.

nursing note for influenza vaccine Date fields to fill

It's essential to highlight the fundamental particulars in the Date, and Time section.

step 3 to filling out nursing note for influenza vaccine

Step 3: When you hit the Done button, the ready document is readily exportable to any type of of your devices. Alternatively, it is possible to deliver it via email.

Step 4: To avoid any hassles as time goes on, be sure to create a minimum of a couple of copies of the document.

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