DATE
CLINIC LOCATION
INFLUENZA VACCINE DOCUMENTATION AND CONSENT FORM
Birthdate M F
Phone
Employee ID
Name
Address
City, St, Zip
Employee Status Active Employee Retired Employee
Are you enrolled in a CPS Health Insurance Plan? YES NO
Have you ever had a severe allergic reaction to eggs? YES NO
Are you allergic to thimerosal (a preservative) other than contact lens sensitivity? YES NO
Have you ever had Guillain-Barre Syndrome or under care for a neurological disorder? YES NO
Have you ever had a reaction to the influenza vaccine? YES NO
Do you have sensitivity to latex? YES NO
Do you have a fever or any illness at this time? YES NO
Pregnant? Are you pregnant or attempting to become pregnant? YES NO A note from your doctor is required if you are in your first trimester
Patient Signature Date
THIS SECTION TO BE COMPLETED BY NURSE
Vaccine Temperature Check °F
Manufacturer COVID Screening Q&A YES NO
Lot Number Deltoid Site LEFT RIGHT
Expiration Date Reaction YES NO
Administered by Signature
2020-2021 Quadrilvalent Vaccine: A/Guangdong-Maonan/SWL1536/2019 (H1N1), A/HongKong/2671/2019 (H3N2), A/ Wisconsin/67/2005 ( H3N2); B/Washington/02/2019 (B Victoria lineage), B/Phuket/3073/2013 (B Yamagata lineage) B/Malaysia/2506/2004;
Risk and Possible Side EffectsInfluenza vaccine generally causes only mild side effects that occur at low frequency. Most commonly, the reactions may be sore or tender arm at the injection site, or possible fever, chills, headache or muscle aches. These effects usually last 24-48 hours. Most people who receive the vaccine either have no or mild reactions. There is a possibility, as with any vaccine or drug that an allergic or other serious reaction, even death, could occur. Moreover, untoward medical events completely unrelated to vaccine administration may occur coincidentally in the aftermath period following vaccination. Unlike the 1976 swine influenza vaccine, flu vaccines used subsequently have not been clearly associated with an increased frequency of Guillain-Barre’ syndrome, which is associated with paralysis. By signing below, I understand I am receiving the flu vaccine.
First Timer? YES NO If yes, please plan to wait at least 15 minutes after your shot for observation. Let the nurse if you have any concerns or reactions.
Top Related