Weight:
kg
Allergies
 No known
Length/Height:
cm Age: ________________ mth/yrs
 Allergies:
Influenza Vaccination: All inpatients aged 6 months of age and older.
When: Every year once season’s vaccine is available through March 31st.
Mark boxes to document patient status (vaccination not indicated):
 Patient is less than 6 months old
 Has anaphylactic latex allergy
 Bone marrow transplant in the past 6 months
 History of Guillain-Barre Syndrome within 6 weeks after
 Received current season’s vaccine
previous influenza vaccine
Date _________________________________(Month/Year)
 Is being transferred to another acute care hospital
 Anaphylactic allergy to eggs (both hives and
GI/cardio/pulmonary symptoms)
Mark box to document patient status (vaccination indicated):
Order:
 Patient (6 – 35 months)
FLU 0.25 mL IM x1
 Patient 36 months and older
FLU 0.50 mL IM x1
Refusal:
 Patient/parent was
offered and declined the
vaccine
 Based on physician’s
recommendation,
patient/parent declined
the vaccine
Pneumococcal Vaccination: All inpatients aged between 5 and 64 years of age who are considered high risk.
High Risk Conditions (chronic illness or immunocompromised): cochlear implants, diabetes, kidney disease, heart disease, lung
disease, damaged or no spleen including sickle cell patients, HIV, AIDS, lymphoma, leukemia, multiple myeloma,
immunosuppressive therapy, and asthma (19 years and older).
Mark box to document patient status (vaccination not indicated):
 Does not have high risk condition
 Less than 5 years old
 5-18 years old with asthma and no other high risk condition
 Received vaccine within the last 5 years
 Allergy/sensitivity to vaccine
 Hypersensitivity to component of vaccine
 Bone marrow transplant in the past 12 months
 Organ transplant during current admission
 Chemotherapy or radiation in the past 2 weeks
 5 – 7 years old and vaccines up to date
 5 – 18 years old and received a conjugate vaccine (PCV13)
in the past 8 weeks
 Being transferred to another acute care hospital
 Pregnant (not delivered before discharge)
Mark box to document patient status (vaccination indicated):
Order:
Refusal:
 Patient (5-7 years) with vaccines not up to date, or unknown
 Patient (8-18 years) with no history of receiving PCV13
PCV13 0.5 mL IM x1
 Patient (5-18 years) received PCV13 more than 8 weeks ago and has
not received PPV23 vaccine in the last 5 years
 Patient (19 and older) is pregnant and will be vaccinated after
delivery
PPV23 0.5 mL IM x1
 Patient/parent was offered
and declined the vaccine
 Based on physician’s
recommendation,
patient/parent declined
the vaccine
Nurse Signature/Printed: _______________________ /______________________Date: ___________ Time:
Patient Label
Pneumococcal and Influenza Vaccines
MEC Approved Protocol
Form# 0050323 (Rev. 01/15)