Mass Immunization Consent

2009-2010 (H1N1) INFLUENZA

I have read or had explained to me the "Vaccine Information Statement" for the influenza vaccine. The information below is required to be entered into the CHIRP registry for Mass Immunizations and will not be used in any way other than accounting for the number of vaccines used in Morgan County.

(Have you had an MMR, Chicken Pox shot, or FluMist in the past month? Yes / No)

First Name: ________________________

Middle Name: ________________________ Birth Date: _____________________

Last Name: ________________________ Sex: Male / Female

Address:

Street: ________________________

Zip Code: ________________________ City: _____________________

State: ________________________ Phone Number: ___________________

Guardian Info:

Mother's Maiden Parent/Guardian

Name: ________________________ First Name: ______________________

(Last Name Only)

Serious Conditions: None / Asthma / Guillian Barre' Allergies: None / Eggs / Other: .

Signature:_____________________________________Date:__________________________

****************************DO NOT WRITE BELOW THIS LINE******************************

Campaign: FLU IMMUNIZATION CLINIC

Tier: Pregnant Women Health Care/EMS Personnel Person caring for child < 6mos.

Child 6mos.-Adult 25 years Adults 25 yrs. - 64 yrs. with chronic medical conditions Others

Vaccination Date: _________________

Vaccine: Manufacturer / Lot #:

Inactive 48+ mos. pres. free CSL Ltd / .

Inactive 48+ mos. w/Thimerosal GlaxoSmithKline / .

Split 18+ years pres. free Medimmune / .

Split 36+ mos. Novartis AG / .

Split 36+ mos. pres. free Sanofi-Aventis / .

Split 6-35 mos. pres. free

Nasal Spray Route: Nasal

Whole IM Left/Right Arm/Thigh

Split 6-35 mos.

Vaccinator Signature/Date: _________________________________________________