Student & Employee Health
Influenza Consent Form
2015-2016
Name:
D.O.B.
Street Address:
City:
State:
Zip:
Department/School:
Precautions/Contraindications to Flu Vaccine
Please circle
Do you currently have a fever, respiratory illness or any other type of infection?
Yes No
Do you have any hypersensitivity to any component of the vaccine, including,
Thimersol, eggs or egg protein?
Yes No
Do you have a history of Guillain-Barre syndrome?
Yes No
*Guillain-Barré syndrome is a rare illness where a person’s own immune system attacks their nerve cells, causing
muscle weakness and occasionally paralysis.
Are you pregnant?
Yes No
Have you ever had a bad reaction to any other vaccines?
Yes No
Please list the vaccine and the adverse reaction: ________________________________
______________________________________________________________________________
Signature: __________________________________Date_______________________________
CLINICAL USE ONLY
INFLUENZA VACCINE:
Injection Site: (circle) LD RD
Signature of Vaccine Administrator:________________________________Date:____________________
Manufacturer:
* All pertinent information will have to be completed before vaccine can be administered*
Revised 9/2015