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2009 h1n1 influenza vaccine consent form for use with either intramuscular, injectable formulation or live attenuated, intranasal formulation of vaccine
H1N1 Influenza Vaccine School Pre-Registration Form
Information about Child to Receive Vaccine (Please Print)
STUDENT’S DATE OF BIRTH
Month_________ Day________ Year __________
MOTHERS MAIDEN NAME
PARENT/GUARDIAN DAYTIME PHONE NUMBER:
Screening for Vaccine Eligibility
The answers to the following questions will help us determine if your child can get the 2009 H1N1 influenza
vaccine. Please mark YES or NO for each question.
1. Does your child have a serious allergy to eggs?
2. Does your child have any other serious allergies?
Please list: ___________________________________________ 3. Has your child ever had a serious reaction to a previous dose of influenza vaccine?
4. Has your child ever had Guillain-Barré Syndrome (a type of temporary severe muscle weakness)?
Your answers to the following questions will help us know which type of vaccine your child can get (Injection or
1. Has your child gotten vaccinated with any of these vaccines within the past 30 days?
MMR Date: ___________ Varicella Date: ____________ Seasonal Flu Mist Date: ______________ 2. Does your child have any of the following:
Asthma, diabetes (or other type of metabolic disease), or disease of the lungs, heart, kidneys, liver, nerves, or blood? 3. Is your child on long-term aspirin or aspirin-containing therapy?
(For example, does your child take aspirin every day) 4. Does your child have a weak immune system?
(For example, from HIV, cancer, or medications such as steroids or those used to treat cancer)?
6. Does your child visit a hospitalized person who needs care in a protected environment?
(For example, a hospitalized person who has had a bone marrow transplant)
Permission to Share Registration Information with Your Clinic
If you check “yes” to permission to share, your pre-registration information will be shared with the medical clinic you indicate. If the type of
vaccine you require is not available through Countryside, your pre-registration will be sent on to your medical provider, so they can provide the
Yes, Countryside has permission to share the information on this registration form with the clinic listed below.
Clinic Name: ___________________________________________
Method for Notifying You of Vaccine Availability
How would you like to be notified of vaccine clinic dates and times?
E-mail Address: _______________________________________________________
Text message – phone # ______________________________________
Phone message – phone # _____________________________________
Mail (list address, if different from above _________________________________________________________)
Date: ______________________ Parent/Guardian Signature: _____________________________________________________
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