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Seasonal Flu Vaccine Screening / Consent Form
The following questions will help us determine if there is any reason we should not give you or your child inactivated
injectable influenza vaccination today. If you answer “yes” to any question, it does not necessarily mean you (or your
child) should not be vaccinated. It just means additional questions must be asked. If a question is not clear, please ask
your healthcare provider to explain it.
VACCINE ADMINISTRATION CONSENT SIGNATURE
I received a copy of the Influenza vaccine information statement (VIS). I read it or had it explained to me. I had an opportunity to ask
questions which were answered to my satisfaction. I understand the benefits and the risks of the vaccine and request that the
vaccine indicated be given to me or to the person named on the registration form for which I am authorized to make this request.
Authorized Signature: _____________________________________ Date: ____________________________
(Self/Parent/Guardian)
The California Immunization Registry (CAIR) is a confidential, secure computer system supported by the California
Department of Health. The system makes it easier for doctors, patients and parents to keep track of shots over a
lifetime. Thousands of California doctors use CAIR. A record of the vaccine you received today will be entered in the CAIR
system. Check this box if you DO NOT want your vaccination to be shared with healthcare providers who use CAIR.
Patient’s Patient’s Patient’s
First Name: __________________________ Last Name: ______________________________ Date of Birth: _____/_______/________
Street Zip Patient’s
Address _____________________________________ City: __________________________ Code: _____________ Age:_______
Phone Mother’s
Number: __________________________________ Gender: ___________________ First Name: ____________________________
Race and Ethnicity Information (check all that apply)
American Indian or Alaska Native Asian Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
Other ________________________ More than One Race
Medical Information
1. Do you feel sick today or have a fever? Yes No
2. Do you have allergies to medications, eggs, a vaccine component, or latex? Yes No
3. Have you ever had a serious reaction after receiving a flu vaccination? Yes No
4. Have you ever had Guillain Barre Syndrome? (A severe paralytic illness also called GBS) Yes No
FOR STAFF USE ONLY
After completion, please Fax this to 510-268-2333 or send copies to ACPHD, Attn: Leslie Greenwood, 1000 Broadway, Suite 500 – Oakland CA 94607
Vaccine type:___________________________ Dose:__________________ Manufacturer: ________________________
Lot #: __________________________ Expiration Date: _____________________ Injection Site:_______________________
Clinic/Site Name and City_____________________________________________________ Credential:
Dispensing Health Care Provider’s Name and Signature: MD RN LVN NP/PA Paramedic
Name: _____________________________Signature: ____________________________DATE:_______________