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Flumist immunization screening and consent form
CCUSD FLU VACCINE SCREENING AND CONSENT FORM FOR 2013-14
Healthy people 2 years of age to 49 years of age are eligible to receive the Nasal Flu Mist.
People 50 years of age or older are only eligible to receive the inactivated Flu Shot.
Print name of individual to be vaccinated (Last name, First name)
School/site: OCD EM ER FA LB LH CP MS HS DO Grade____ Classroom_____ Teacher___________________
Part A - HEALTH INFORMATION:
Does the person being vaccinated have any of the following health conditions? YES, mark all that apply below NO
_____ Asthma (wheezing if under 5 years of age or others requiring daily preventative medications) or Lung Disease _____ Heart disease
_____ Metabolic disease (including Diabetes)
_____ Weakened immune system (steroid therapy, under cancer treatment, HIV, etc.)
_____ Live with or expect to have close contact with a person whose immune system is severely weakened and who must be in a protective environment?
_____ Taking anti-viral medications (such as Tamiflu, Relenza, amantadine, or rimantadine) _____ Persons under 18 years of age taking long-term aspirin treatment _____ Received MMR, Varicella or live flu vaccine within the last 4 weeks _____ Currently pregnant or breastfeeding
If you checked “YES” to any of the health conditions listed above, you cannot receive the nasal FluMist;
you may be eligible to receive the inactivated Fluzone flu shot. Please answer the following three questions:
Is the individual being vaccinated severely allergic to eggs or latex?
Has the individual being vaccinated had a serious reaction to a previous flu vaccination?
Does the individual being vaccinated have a history of a Guillain-Barre Syndrome?
If you checked “YES” to any one of the above questions, we cannot administer the Fluzone Flu vaccine.
You may be able to receive a different flu vaccine. Please consult with your doctor.
Part B - PREVIOUS FLU VACCINE INFORMATION: (Only if person being vaccinated is under 9 years of age)
Did your child under 9 receive a vaccination for flu last year?
how many doses of the flu vaccine did your child get last year?
1 dose** or 2 doses (skip to Part C)
**If only one dose
last year, did your child receive a flu vaccine the previous year? YES (skip to Part C) NO
If your child is under 9 years of age and has not previously been vaccinated for the flu with 2 doses
of either the nasal mist or injection, they will need a second vaccination in 4 weeks.
I hereby give consent for the second flu vaccine for my child under 9. Parent/Guardian initials here: ________
Part C – WRITTEN CONSENT:
I have read the current Influenza Vaccine Information Statement (VIS) dated 7/26/2013 and understand the benefits and risks
of flu vaccination. I also understand that this immunization will be recorded on the California Immunization Registry, which
can be viewed by other healthcare professionals. I agree to these terms and consent to the administration of the flu vaccine.
If requesting this vaccine for a child under the age of 18, I hereby give my permission for the flu vaccine to be administered
and certify that I am authorized to make this request. Parent/Guardian initials here: _________
Signature of person requesting vaccination
REQUIRED INFORMATION: for data entry - First name of Mother (of person being vaccinated): ______________________
for LA County data collection - Ethnicity (of person being vaccinated): ___________________
FOR CLINIC USE ONLY:
Brands: FluMist, Lot #BH2090, Exp date: 12/02/13
Fluzone injection, Lot #UH899AE, Exp date: 06/30/2014
Victoria A. Coburn, MD, Mark B. Mycyk, MD Physical restraint Chemical restraint Violence Safety SedationCombative and violent patients are commonly encountered in the emergency depart-ment These patients may be brought in by concerned family members, referredto the ED by other health professionals, or transported by police or emergencymedical services (EMS) personnel for causing a public
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