Student influenza vaccination consent form
2012-13 STUDENT INFLUENZA VACCINATION CONSENT FORM
Health Department Use Only
Parent/Guardian Phone # Home: _________________ Cell: _______________ Work: _________________ Please check YES or NO
to the questions below to determine if your child can receive FluMist® (live attenuated nasal spray vaccine) or
the flu shot (inactivated vaccine). The nurse giving the vaccine will review this information on the vaccine clinic day.
1. Has your child ever had a serious allergic reaction to eggs or to a component of any flu vaccine?
2. Has your child ever had a serious reaction to a previous dose of flu vaccine in the past?
3. Has your child ever had Guillain-Barré syndrome (GBS, i.e., progressive ascending paralysis)?
If you answered YES to any of questions 1, 2 or 3 above, flu vaccine may not be safe for your child and s/he WILL
NOT receive a flu vaccine. If you answered NO to questions 1, 2 or 3, please continue below.
4. Does your child have a long-term health problem such as heart disease, kidney or liver disease, lung disease
(e.g. wheezing or asthma
), metabolic disease (e.g. diabetes
), or blood disorders (e.g. anemia
5. Does your child have a weakened immune system because of cancer, cancer treatment (e.g. x-rays or drugs),
HIV/AIDS, other disorders, or medicine (e.g. high dose steroids)?
6. Does your child live with or expect to have close contact with a person whose immune system is severely
compromised who must be in protective isolation (e.g., an isolation room of a bone marrow transplant unit)?
7. Is your child on long-term aspirin therapy or take other aspirin-containing medications?
8. Is your child taking any prescription medications to prevent or treat flu?
9. Has your child received MMR (measles/mumps/rubella) or varicella (chickenpox) vaccine in the past 4 weeks?
10. Is your child pregnant or could she become pregnant within the next month?
If you answered YES or left blank any questions from # 4 through # 10 or if your child is younger than 2 years old,
your child WILL NOT receive FluMist®, but she/he CAN RECEIVE the flu shot.
NOTICE OF DEEMED CONSENT FOR HIV, HEPATITIS B OR C TESTING
VDH is required by § 32.1-45.1 of the Code of Virginia (1950), as amended, to give you the following notice:
If any VDH health care professional, worker or employee should be directly exposed to your child’s blood or body fluids in a way that may transmit disease, your child’s blood will be tested for infection with human immunodeficiency virus (HIV), as well as for Hepatitis B and C. A physician or other health care provider will tell you the result of the test. Under Va. Code § 32.1-45.1(A), you are deemed to have consented to the release of the test results to the person exposed.
If your child should be directly exposed to blood or body fluids of a VDH health care professional, worker or employee in a way that may transmit disease, that person’s blood will be tested for infection with human immunodeficiency virus (HIV), as well as for Hepatitis B and C. A physician or other health care provider will tell you and that person the result of the test.
CONSENT FOR CHILD’S VACCINATION: In October 2012, will your child be less than 9 years of age? No
My child is 9 years of age and older.
I understand my child will receive one dose of influenza vaccine.
My child is under 9 years of age
Has NEVER been vaccinated against the flu. Note: Your child will require 2 doses this year
Has not been vaccinated with at least 2 doses of seasonal influenza vaccine since July 1, 2010. Your child will require 2 doses
I have read the 2012-2013 Vaccination Information Statements (VIS) for the flu shot (inactivated vaccine) and for FluMist (live, intranasal vaccine). I understand the risks and benefits, and I give consent to the Health Department and its authorized staff for my child named at the top of this form to get vaccinated with this vaccine. I understand the decision on the type of vaccine administered will
depend on my child’s history. I prefer my child be given the (PLEASE CHECK ONE)
Signature of Parent or Legal Guardian: X_ _____________________________________________Date: ____/_____/____
Please answer the following: *Note
: This information is required for federal funding purposes for VFC vaccine. It will not prevent your child from
receiving vaccines through this program.
My child: ( ) has Medicaid
(Please choose one of the following) Medicaid #
____Optima Family Care
____Anthem Healthkeepers Plus
____Medicaid Fee for Service
(Not a Managed Care Organization)
( ) is not
insured (by private insurance, Medicaid, or FAMIS)
( ) is American Indian or is an Alaska Native
( ) has F
ccess to M
( ) has other private insurance
not listed above (Medicare, Anthem, UMWA, Black Lung)
Name of Insured/Policy Holder ___________________________ Relationship to child __________
Insurance ID/Subscriber # _________________________________
I authorize VDH to release records necessary to support the application for payment by Medicare, Medicaid, and other health care benefits. I request the third party payer to pay any authorized benefits to VDH on my behalf.
Office of Privacy and Security
Authorization for Disclosure of Protected Health Information
As the person signing this authorization, I understand that I given permission to the Virginia Department of Health (VDH) to disclose personal health information to the person(s) or organization(s) I have indicated.
I understand the provision of treatment to my child cannot be conditioned on my signing of this authorization.
Any health information redisclosed by me or my child will no longer be protected by this authorization.
The original or a copy of the authorization shall be included with my child’s medical record.
I have the right to revoke this authorization at any time, except to the extent that action has been taken prior to my request to withhold my medical record. The request must be in writing and will be effective upon delivery to the provider in possession of my medical records.
I authorize VDH to disclose my child’s health information to his/her primary care physician and school.
I understand that this record will be retained for ten years after the last visit or for five years after age 18, whichever comes later.
I understand this document will be given to and retained by the public health department and will not be maintained by the school.
Please check box if you wish to receive a copy of the Virginia Department of Health Privacy Rights.
I understand that the Virginia Department of Health will not release private medical records unless authorized above
or to continue care.
Optional: If requested, please send a copy of my child’s immunization record to her/his doctor at the following address.
Doctor’s Name_________________________ Mailing Address________________________________ City___________________ State__________ ZIP______________
HEALTH DEPARTMENT USE ONLY
Vaccine Administration Site Provider #
FLU-PFA (single dose)
FLU-SP (multi dose vial)
Provider Name/Signature and Date
FOR POD (EP&R) PURPOSES ONLY:
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