Age 3 Years to Adult
3-8
yrs
2014/2015 ARUP Family Health Clinic
INFLUENZA VACCINE ADMINISTRATION RECORD
Full name: _______________________
Phone number: _(____)____-________
Date of birth: ____/_____/______ Age: _________
Please select one of the following:
dependent, spouse, or domestic partner of an ARUP Employee
I am an ARUP employee and my ARUP ID number is ______________________________
Yes
No
Have you ever had a severe allergic reaction to eggs or egg product?
o
o
Have you ever had a severe allergic reaction after receiving a flu vaccine?
o
o
Do you currently have a moderate to severe illness (ex. pneumonia)?
o
o
Have you been diagnosed with Guillain-Barre disease (ie. severe loss of muscle
function) after receiving a flu vaccine?
o
o
Yes
No
For clinic use
Did you receive at least one dose of the flu vaccine last year? (2013-2014)
o
o
Did you receive a total of at least two doses of flu vaccine since 2010?
o
o
If either “yes”
= 1 dose
Both “no”
= 2 doses
Please answer the following questions:
If you are less than 9 years old, please also answer the following:
I have read or have had explained to me the information in the VIS (8/19/2014) about influenza and influenza vaccine. I
have had a chance to ask questions that were answered to my satisfaction. I understand that this health care treatment
carries a risk of harm; I accept such risk on behalf of myself and/or my child in the hope of obtaining the protective effects
of immunization. I understand that the health care provider does not warrant the quality of the manufacturer’s vaccine or
guarantee that adverse reactions will not occur. After considering the benefits and risks associated with this vaccine, I
hereby give consent to be vaccinated.
SIGNATURE FOR CONSENT (SELF OR GUARDIAN)
DATE
Relationship to Patient:
For Clinic Use
MRN: _______________
Confirm dose 0.5 mL
Initial _______
Date of administration:
Vaccine Manufacturer:
Sanofi
Exp___________
Lot__________
Site of injection (circle):
Right or Left
Deltoid
IM
Vaccine Reviewed with:
_________________________
Vaccine Administered by:
___________________________
(full name)