School Clinic Influenza Vaccine Administration Record and Consent Form
Child’s Name:____________________________________________ Date of Birth:____________Age:___
Parent’s Name:__________________________________________ Daytime Phone:________________
Address:_________________________________City:__________________________Zip:____________
Please answer the following questions: If there is any change in your child’s health history on the day of the
clinic, please contact LaSalle County Health Department so we can update the information. (815-433-3366)
Does the person to be vaccinated have an allergy to eggs?
Yes
No
Has the person to be vaccinated ever had a serious reaction to influenza vaccine in the past?
Yes
No
Does the person to be vaccinated have a long-term/chronic problem with their heart, lungs, asthma, kidneys, neurologic
or neuromuscular disease, liver, metabolic disease (e.g., diabetes), anemia or other blood disorder? Yes__ __No
If the person to be vaccinated is between 2-4 years, in the past 12 months, has a healthcare provider
ever told you the he/she had wheezing or asthma?_________________________________________Yes
No
Does the person to be vaccinated have a weakened immune system because of HIV/AIDS, Leukemia, Cancer, other
diseases of the immune system or is on long term treatment with drugs such as high dose steroids, cancer or radiation
treatment?
Yes
No
Is the person to be vaccinated receiving antiviral medications?
Yes
No
Is the child to be vaccinated on Aspirin therapy or Aspirin-containing therapy?
Yes
No
Is the child to be vaccinated pregnant or could become pregnant within the next month?
Yes
Has the child to be vaccinated ever had Guillain-Barre` Syndrome?
No
Yes
Does the child live with or have close contact with a person who is severely immune compromised?
Yes
Has the child to be vaccinated received any other vaccinations in the past 4 weeks?
Yes
No
No
No
I authorize LaSalle County Health Department to provide Influenza Vaccine to my child named on this form. I have been made aware that I
can contact LCHD with any questions I have. I have also been provided the information necessary to access an Influenza Vaccine Information
Statement (VIS) to read prior to the date of the clinic.
Parent/Guardian Signature:_________________________________________________ Date:____________
*Please complete:*
I have a Medical Card or All Kids Card. Please copy and attach to form.
I have private insurance which pays for Flu Shots. Please include a $25.00 payment with this form.
An insurance receipt will be provided to the child the day of the clinic.
I have private insurance or no health insurance which pays for Flu Shots. Please include a $10.00
payment with this form.
Nurses Signature___________________________________________________Date:_____________Lot#________