Seasonal Influenza Vaccine Consent Form 2014-2015
Name:(Last)
(First)
C#:
Date of Birth (e.g., 1/2/1972)
Job Title or Position:
Department Name:
Work Phone:
Work Address:
Building Name:
Room#:
□Medical
□Gables □RSMAS □UMHC/SCCC □BPEI □UMH □Other_
□MD □Med Student □PhD □ARNP □PA □RN □Other UM Student □Other:
Work Location:
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Our influenza vaccine, Fluzone, is latex and thimerosal free.
Possible reactions to vaccine:
Mild: Soreness or redness at the site of the shot; fever; body aches.
Severe: Acute allergic reaction – high fever; confusion; difficulty breathing; hives; rapid heartbeat – would occur within a few minutes of
the shot). Guillain-Barre Syndrome – progressive muscle weakness and paralysis –may occur days to weeks after the vaccine - (does
not occur in increased frequency after flu vaccination).
Egg allergy: If you tolerate lightly cooked eggs (e.g., scrambled eggs), you can be vaccinated. If you have hives or anaphylactic reactions to
egg products, there are alternative vaccines that will be discussed with you.
1.
2.
3.
4.
Do you feel sick or have a fever? (come back when you are not sick)
Do you have severe allergy to eggs?
Have you ever had a severe reaction to a flu vaccine?
Have you had Guillain-Barre Syndrome?
□ Yes
□ Yes
□ Yes
□ Yes
□ No
□ No
□ No
□ No
If you have had recent chemotherapy, radiation therapy, or steroids, these conditions may decrease the effectiveness of the vaccine. However,
flu vaccination is still recommended. Flu vaccination is recommended for any woman who will be pregnant or who will be breastfeeding during
the influenza season. Vaccination can occur in any trimester.
Consent
I have read the Influenza vaccine information sheet given to me. I have been provided an opportunity to ask questions about influenza and
its treatment. I understand the risks and benefits of the vaccination. I understand that the vaccination that I am about to receive is a single
shot and it will not be fully effective for approximately two
weeks. However, as with all vaccines, there is no guarantee that I will become immune or that I will not experience side effects. I understand
that I should not receive this vaccine if I have a severe allergy to eggs, have had a severe reaction to a previous influenza vaccine, or if I have
had Guillain-Barre Syndrome. I hereby consent to have the influenza vaccine.
Signature of Vaccine Recipient:
Date:_____________
Do not write below this line. OFFICE USE ONLY
Name of Flu vaccine:
Lot #:
Dose 0.5cc IM
VIS Date:08/19/2014
Manufacturer:
Expiration Date:
□
Location:
R Deltoid
Administered by:
PRINT NAME:
Today’s Date:
□
L deltoid
JOB TITLE: