H1N1 VACCINATION FORM - ENGLISH VERSION - PRINT OUT PLEASE


 

 
 
I have read or had explained in the "Vaccine Information Statement(s)" or the "Important Information Statement(s)" for the
disease(s) and vaccine(s) checked below.  I have had a chance to ask questions and fully understand the benefits of the
vaccine(s) checked below.  I request that this vaccine be given to the person named below.    
                     
O  H1N1 Vaccine                  
                     
Last Name:   First Name:   Middle Name: Date of Birth:  
                     
Birth State: Birth Country:   Gender:   Age: (6 months to 9 years will receive an
                additional vaccine in 4 or more weeks)
Race: O White O African American O Asian O Multi-Racial Hispanic Origin:    
  O American Indian O Other       O Hispanic    O Non-Hispanic O Unknown
Mother's Maiden Name:                
                     
Guardian 1 Last Name:   First Name:   Middle Name:    
                     
Guardian 2 Last Name:   First Name:   Middle Name:    
                     
Mailing Address for Responsible Adult:              
O Mother O Father O Other (specify)              
Last Name:         First Name:      
                     
Address:           Home Phone:   Work Phone:
                     
City:       State:     Zip:      
                     
WARNING: Some people should check with a doctor before taking the H1N1 flu vaccine.  Does this person have:
O An allergy to eggs or egg products?            
O An allergy to Thimerosal?              
O A history of Guillain Barre Syndrome or other neurological disorders?      
O Have you previously had a severe reaction to the flu shot? (Hives, rash that covers the body, difficulty breathing, etc.)
O Do you currently have a fever or flu like symptoms?          
O Have you had a seasonal flu vaccine recently?             If so-when:      
CONSENT FOR VACCINATION:     VACCINATION REFUSAL:    
I GIVE CONSENT to the STATE/LOCAL health department and its staff       I DO NOT GIVE CONSENT  to the STATE/LOCAL
for person named above to be vaccinated with this vaccine.     health department and its staff for person named
If this consent form is not signed, dated, and returned, the vaccine     above to be vaccinated with this vaccine at this time.
will not be given.                  
                     
Signature of person to receive vaccine(s) or person authorized to Signature of person refusing vaccine(s) or person
consent to the immunization(s) (6 months to 9 years will receive an authorized to refuse the immunization(s)  
      additional vaccine in 4 or more weeks)          
                     
Signature           Signature        
                     
                     
Printed Name     Date   Printed Name   Date  Page 1
                   
                   
                           VACCINE ADMINISTRATION      
                                  PATIENT RECORD        
                     
Last Name:   First Name:   Middle Name: Date of Birth: Age:
                     
                     
Priority Tier:                  
Please check which one pertains to the person receiving the vaccine:        
□ Pregnant                  
□ Live with or care for infant younger than 6 months of age        
□ Health care giver or emergency personnel            
□ Age 6 months through 24 years              
□ 25-64 years old with chronic medical conditions          
□ Healthy adult 25-64 years old              
□ Adult 65 and over                
                     
DO NOT WRITE BELOW THIS LINE-For Clinic Use Only!        
                     
Vaccine                Date Dose         Dose Number   Dose Administered:     Administered IM in:  
       Administered 1st 2nd  □  0.25 ml (6 months - 2 years)      □  Left Deltoid  
2009 H1N1          □  0.5 ml (3 years and older)      □  Right Deltoid  
2009 H1N1                □  Left Vastus Lateralis  
Manufacturer:              □  Right Vastus Lateralis
Expiration Date:                  
Lot Number:                  
VIS dated:  10/02/09              □  Intranasal    
                     
Vaccine Administrator Signature:              
                     
Clinic Location:                  
               Ripley County Health Department:  102 West 1st North Street, Versailles, IN  47042  Phone:  812-689-5751  Fax:  812-689-3909

© Copyright 2009 Ripley County Health Department