EMPLOYEE INFLUENZA IMMUNIZATION CONSENT FORM 2012-2013
Hospital
Department:
Location:
Employee ID#
Print
Full Name:
Volunteer ID#
PLEASE PRINT CLEARLY
Have you received influenza vaccine already this season (Aug. 2012 – June 2013)? If yes, please note date:
IF YOU WISH TO RECEIVE INFLUENZA VACCINE, PLEASE ANSWER THESE QUESTIONS:
Yes
No
Yes
No
1. Are you sick today?
2. Have you ever had a serious reaction (anaphylaxis) to a previous dose of influenza vaccine, to eggs, latex, or to a
vaccine component (see list below)?
3. Have you had Guillaine Barre′ syndrome within 6 weeks of a previous dose of influenza vaccine?
FOR INTRANASAL INFLUENZA VACCINE (LAIV), PLEASE ANSWER THESE ADDITIONAL QUESTIONS:
1. Are you 50 years of age or older?*
2. Do you have a long-term health problem with heart disease, lung disease, asthma, kidney disease, neurologic or
neuromuscular disease, liver disease, metabolic disease (e.g., diabetes), or anemia, or other blood disorders?*
3. Do you have a weakened immune system because of HIV/AIDS or another disease that affects the immune
system, long-term treatment with drugs such as high-dose steroids, or cancer treatment with radiation or drugs?*
4. Have you taken antiviral medications (e.g., amantadine, rimantadine, zanamivir, oseltamivir) in the past 48 hours?*
5. Are you pregnant or could you become pregnant within the next month?*
6. Do you have close contact with severely immunocompromised persons in protective isolation?*
7. Have you received MMR, varicella, or yellow fever vaccine in the past 4 weeks? If yes, you should receive the
injectable vaccine or wait 28 days before receiving LAIV.
*If you answered ‘yes’ to any of this group of questions, you should receive the injectable influenza vaccine.
Vaccines available
Components (see package insert for additional information)
TIV — Fluzone, Sanofi Pasteur, 0.5 mL IM
Egg protein
Formaldehyde
Does not contain thimerosal or latex.
Egg protein
Gentamicin
Does not contain thimerosal or latex.
LAIV — FluMist, MedImmune, 0.2 mL intranasally
Gelatin
Gelatin
Arginine
Approved by:
[physician’s signature]
[enter name, title of physician]
Section 164.512() permits a covered entity to disclose protected health information to the government for public health activities. Please note that this
immunization record will be electronically transferred to [hospital name’s] EMR system or entered via employee health flu clinic module in EPIC and
Minnesota Department of Health’s Immunization Registry.
I have received, read, and/or have had explained to me the information about influenza vaccine (i.e. Vaccine Information Statement).
I have had a chance to ask questions that were answered to my satisfaction. I believe I understand the benefits and risks of the
influenza vaccine and ask that the vaccine be given to me. I understand that it is recommended to wait 15-20 minutes after the
immunization in case of allergic reaction or light headedness.
Signature:
Today’s date
The American Nurses Association, the Minnesota Department of Health, The Joint Commission, and [hospital name]
recommend that employees receive influenza vaccine annually. The reasons for getting immunized against influenza are many:
1) Protect yourself. If you get influenza, you can miss a week or more of work and pay.
2) Protect your loved ones. If you get influenza, you can spread it to your family and loved ones. Older people, young
children and people with chronic illness are especially vulnerable to getting seriously sick from influenza.
3) Protect your patients and your co-workers. If you get influenza, you can spread it to people you work with, and to
patients that you care for. Many of our patients are at high-risk for influenza-related complications, which can result in
death. It's a patient safety issue.
Not a chart form. Send this form to [hospital/clinic department name].