VON Canada Immunization Program
IMMUNIZATION DOCUMENTATION FORM
(Use for Influenza and other Specific Vaccines)
 Required Information
Date:
Clinic:
VON Site: Edmonton
Posted:
Privacy Statement
Client Bill Rights & Responsibilities
Client Personal Information - person receiving the vaccine to complete (please print)
 Last Name
Date of Birth
Address:
 First Name
Male
Female
 Gender
 Age
Unit/Apt#
 Weight: (children under 14 yrs)
Street
Pounds ________
Health Card/Medicare Number
Phone Number
City
Province
Postal Code
Kilograms _______
Client Vaccine Health Screening - person receiving the vaccine to complete (check the right box)
This checklist helps the nurse decide whether to give you the vaccine
YES
1.
Have you ever had the vaccine before?
2.
Have you ever had any problems getting vaccines or needles?
3.
Have you ever had a life threatening allergic reaction (e.g. vaccine, drug, food, substance)?
4.
Are you ill today (serious fever or active infection)?
5.
Have you received a vaccine in the past 4 weeks?
6.
Do you have a weak immune system due to health condition or treatment?
7.
Do you bleed easily due to a health condition or medication?
8.
Have you developed Guillain Barré syndrome (a disorder of the nerves & muscles) after getting a vaccine?
9.
For women: Are you pregnant or breast feeding?
NO
Don’t
Know
Client Consent - person receiving the vaccine to read and sign below when you are with the nurse
I have read the vaccine fact sheet and/or had it read to me. I have had a chance to ask and have my questions answered. I am
aware of the risks, benefits, side effects and reasons not to get the vaccine.
I am aware that I am to stay in the clinic for 15 minutes after receiving the vaccine.
I authorize
(print nurse’s full name) to give
(vaccine)
and any emergency care that is needed for the person receiving the vaccine as listed above under personal information.
Signature of Client or Substitute Decision Maker:
Name of Substitute Decision Maker (print):
Name of Nurse obtaining consent (print):
© Victorian Order of Nurses for Canada, 2006
Relationship:
Parent
Guardian
Signature/Designation:
Revised: December, 2010
Due for Review: December, 2013
VON Canada Immunization Program
Record of Immunization (Single dose or Dose 1 in a series) – to be completed by the nurse giving the vaccine
Vaccine:
Dose:
Fluviral
0.25mls
Vaxigrip
0.5mls
Influvac
Agriflu
other ___mls Route:
Intanza
I.M.
Other:
S.C.
I.D. Site:
Injection Time: __________ Flu Recommended Recipient Category:
AEFI:
N/A
ERS completed
Date:
Lot #:
RD
Expiry:
LD
RVL
LVL
N/A ______________________ ROI:
AEFI Documentation Tool completed
Other______
given to client
Public Health report completed
Nurse giving the vaccine Signature/Designation:
(ONY initial if you also obtained the consent)
Record of Immunization (Dose 2 in the series) - to be completed by the nurse giving the vaccine
Vaccine:
Dose:
Fluviral
0.25mls
Vaxigrip
0.5mls
Agriflu
Other: ____________________ Lot #: ______________________ Expiry:____________
other ___mls Route:
I.M.
S.C. Site:
Injection Time: ____________ Flu Recommended Recipient Category:
AEFI:
N/A
ERS completed
AEFI Documentation Tool completed
RD
LD
RVL
LVL
Other____________
N/A ______________________ ROI:
given to client
Public Health report completed
The health screening questions and consent have been reviewed with the client. Document any changes _____________________
______________________________________________________________________________________________________________
Date: ___________ Name of Nurse giving the vaccine (print): ____________________Signature/Designation: ______________________
Record of Immunization (Dose 3 in the series) - to be completed by the nurse giving the vaccine
Vaccine Name: ____________________________ Lot #: ___________________ Expiry:____________________
Dose:
0.25mls
0.5mls
other ___mls Route:
Injection Time: ____________ ROI:
AEFI:
N/A
ERS completed
I.M.
S.C.
I.D. Site:
RD
LD
RVL
LVL
Other_____
given to client
AEFI Documentation Tool completed
Public Health report completed
The health screening questions and consent have been reviewed with the client. Document any changes _____________________
______________________________________________________________________________________________________________
Date: ___________ Name of Nurse giving the vaccine (print): ____________________Signature/Designation: ______________________
Record of Immunization (Dose 4 in the series) - to be completed by the nurse giving the vaccine
Vaccine Name: ____________________________ Lot #: ___________________ Expiry:____________________
Dose:
0.25mls
0.5mls
other ___mls Route:
Injection Time: ____________ ROI:
AEFI:
N/A
ERS completed
I.M.
S.C.
I.D. Site:
RD
LD
RVL
LVL
Other_____
given to client
AEFI Documentation Tool completed
Public Health report completed
The health screening questions and consent have been reviewed with the client. Document any changes _____________________
______________________________________________________________________________________________________________
Date: ___________ Name of Nurse giving the vaccine (print): ____________________Signature/Designation: ______________________
Legend: Route: IM=intramuscular S.C. Subcutaneous I.D =Intradermal Injection Site: RD=right deltoid LD=left deltoid RVL=right vastus lateralis LVL=left vastus lateralis
Injection Time: Enter time in hour and minutes–use 24 Hr clock ROI =Record of Immunization AEFI =Adverse Event Following Immunization ERS=Event Reporting System
Recommended Recipient Category - See Flu Fact Sheet for listing
© Victorian Order of Nurses for Canada, 2006
Revised: December, 2010
Due for Review: December, 2013