Research Occupational Health Program
RABIES VACCINE SERIES CONSENT FORM
Name (Last, First, MI):
Sex: M
F
Date of Birth:
Today’s Date:
Home Address:
Home Phone:
Employer: BU
BMC
Employer ID #:
Department:
Job Title:
Campus:
Work Phone:
BUMC
CRC
Email:
Type of Vaccine: There are three types of inactivated virus cell culture vaccines available. Your healthcare provider will explain the vaccine that was
selected for you.
YES NO
Please check ‘YES’ or ‘NO’ to all of the following:
I received and read the fact sheet entitled “Rabies Vaccine – What You Need to Know” prepared by the CDC dated 10-06-09.
Health Status Information:
Do you have a weakened immune system because of HIV/AIDS, steroid therapy or cancer treatment with radiation or drugs
(chemotherapy)?
Have you ever had an allergic reaction to a vaccination?
Do you have a bleeding disorder or are you taking anticoagulant drugs?
Are you currently pregnant or nursing?
Possible Side
Effects:
Redness, soreness and/or swelling at the injection site. Low fever, fatigue, headache, dizziness or nausea. Serious allergic reaction
(very rare) or respiratory distress (very rare).
Please Read Carefully and Check ‘YES’ or ‘NO’ to all of the following:
I had an opportunity to ask questions and questions were answered to my satisfaction
I understand I may experience mild side effects as indicated above.
I will take responsibility to seek medical attention should more severe symptoms occur.
Employee Signature is Required Below
Signature:
Print Name:
Date:
ROHP Only
Vaccine Information
Day 1
Day 5
Day 21
Manufacturer & Lot #:
Expiration:
Date Administered:
Location:
Left
Deltoid
Right
Left
Deltoid
Right
Left
Deltoid
Clinician Signature:
Revised 3/22/12
Boston University Research Occupational Health Program * 617-414-7647 (ROHP) * www.bu.edu/rohp
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