Sspencer.k12.in.us

Spencer County Health Department
Vaccine Administration Record

I have read or had explained to me the information in the “Vaccine Information Statement(s)” for the vaccine below. I have had a
chance to ask questions and fully understand the benefits and risk of the vaccine (s). I request the vaccine be given the person named
below.
Circle the vaccine preference: Flu injection (shot) Flumist (nasal spray) No preference
Neither vaccine can make the child sick.
Name:Last________________________First__________________________Middle____________________Age_________
Date of Birth_______________________ SSN_________-_______-________ Race:___________ Male______Female______
Address:_______________________________________________________ Phone Number:__________________________
City:______________________________State_________Zip_____________Cell Phone Number:_______________________
*Social Security Numbers may be used to identify patient and are optional on this form. There are no penalties for failure to provide SSN.
**Race may be used for statistical information and is not required information on this form. There are no penalties for failure to provide race.

Questionnaire: Please circle answers

1. Does the child have a life-threatening allergy to eggs?.………………………………………….……….………… Yes No
2. Does the child have a history of Guillain-Barre’ Syndrome (GBS)?. Yes No
(Guillain-Barre syndrome is a neurologic disorder causing temporary paralysis.)
If the answer is yes to any of the following questions, the child should take the flu shot
3. Is the child on long-term aspirin therapy?. Yes No
4. Does the child have severe asthma or current wheezing?. Yes No
5. Does the child have cancer, leukemia, AIDS, or any other immune system problem?.
6. In the past 3 months, has the child taken cortisone, prednisone, other steroids, or anticancer drugs, or had radiation treatments?. Yes No 7. In the past year, has the child received a transfusion of blood or blood products, or been given immune globulin?. Yes No 8. In the past 2 days, has the child taken an antiviral drug like tamiflu or Relenza?. Yes No 9. Is the child/teen pregnant or is there a chance she could become pregnant during the next month?. Yes No 10. Has the child received live vaccinations (MMR or chickenpox vaccine) in the past 4 weeks?. Yes No
VFC Eligibility Screening (Please check appropriate box)

Medicaid: A child who has any form of Medicaid insurance.
American Indian/Alaskan Native: A child who identifies as an American Indian or Alaskan Native, regardless of insurance.
No Health Insurance: A child who does not have health insurance.
Insurance Does Not Cover Vaccines (Underinsured): A child who has commercial (private) health insurance but the coverage
does not include vaccines, children whose insurance covers only selected vaccines (these children are categorized as
underinsured for non-covered vaccines only), or children whose insurance caps vaccine coverage at a certain amount (once that
coverage amount is reached, these children are categorized as underinsured).
Fully Insured: A child who has health insurance which provides coverage for vaccines.

Signature of person authorized to consent to the immunization(s) Spencer County Health Department
Vaccine Administration Record
This Side For Clinic Use
Fluzone sanofi pasteur Lot # UH 438 AA (0.5 ml PFS)
Date of vaccine information statement 7-26-11 Route: Intramuscular Site: Left thigh Right thigh Left arm

Fluzone sanofi pasteur Lot # UH 442 AB (0.5 ml PFS)
Date of vaccine information statement 7-26-11 Route: Intramuscular Site: Left thigh Right thigh Left arm Fluzone sanofi pasteur Lot # UT 4114 BA (0.25 ml PFS)
Date of vaccine information statement 7-26-11 Route: Intramuscular Site: Left thigh Right thigh Left arm
Flumist sanofi pasteur Lot # 501105P
Date of vaccine information statement 7-26-11 Route: Nasal
____________________ ______________________________________ Date Vaccinated and Signature of Vaccine Administrator VIS Provided to Client

Source: http://www.sspencer.k12.in.us/pdf/nurse/2011fluvacconsent.pdf