flu vaccine consent form 2020

FLU VACCINE: The flu vaccine contains influenza virus of the types selected by the US Public Health Service and the Center for Biologic Evaluation and Research of the US Food and Drug Administration. Please also refer to the section below on “Legal issues” for important information on liability, licensing, FERPA, and HIPAA. The nasal flu vaccine contains a highly processed form of gelatine derived from pigs (porcine gelatine). As some influenza SLV programs do not offer second doses of influenza vaccine, these consent forms were developed for programs administering only one influenza vaccine to students. Each of the following materials should be translated and available in various languages, as locally appropriate.

Such a letter also could be sent well in advance of the planned SLV date, perhaps even before vaccine is available in the area. 苧D�a���t@��H�L~�W|>UDE�{�`×��ZK�Uo��3����$"�����,��b���^��_*v�i2��R NþL��� 6��4}�3eRuȗ���~����?���Dp6(�u,����L�q��M��}D�?f6~�x�:W)�Qs�6��z�K[���o����. Because the idea of vaccinating children at school may be unfamiliar to some parents/guardians, there may be reluctance to consent to influenza vaccination at school. Planners should discuss this approach with state and local legal advisors before deciding to implement it. contact information in case parents/guardians have questions or concerns. Drive to the clinic location at the time of your appointment. Consent Form 2020 Quadrivalent Influenza Vaccine Medical History Please answer the medical history questions below. If parental consent for vaccination is obtained substantially in advance of the time that the vaccine is to be administered to the child, a mechanism must be provided for the parent/guardian to withdraw consent prior to the time of vaccination, if desired. I have hada chance to ask questions, which were answered to my satisfaction, and I understand the benefits and risks of the

Influenza Vaccination Required for Faculty, Staff and Students. The benefits of such a procedure, if determined to be legally viable and feasible in the jurisdiction that will be offering influenza SLV clinics, are that vaccine may be expeditiously given to consented children as soon as it is received by the vaccinator, and planners may be better able to plan for adequate staff, vaccine, and supplies. The choice of which consent form(s) to distribute to parents/guardians will depend on which vaccine formulation (live-attenuated intranasal vaccine [LAIV], inactivated injectable vaccine, or both) will be offered at the SLV clinic. The flu vaccine can only prevent influenza… endstream endobj 270 0 obj <>stream KAMEHAMEHA SCHOOLS MĀLAMA OLA HEALTH SERVICES DEPARTMENT Student’s Name: Grade: Student ID: Please sign this consent form if you would like for KS to give your child a flu shot. Below are notes about each section on the template consent forms: Information about child to receive vaccine: This section includes suggestions for collecting personal and demographic information. pediatric vaccine consent form. Parents/guardians may seek the advice of others, including their child’s health care provider (Woodruff, 1996). Additionally, if it is anticipated that LAIV will be offered, plans should be in place to confirm that the child has not received another live vaccine (e.g., varicella or measles, mumps, rubella [MMR] vaccines) within four weeks of the SLV clinic. All rights reserved. Information about the person getting vaccinated. x��\ko�F�n��a�baO8��+( �Q It is offered because it is more effective in the programme than an injected vaccine. 2 0 obj They also include information about indications and eligibility for each vaccine. Keeping providers informed about planned SLV clinics also will help them estimate how much influenza vaccine they will need to order for their own patients. %PDF-1.6 %���� Influenza Vaccine Consent Form (6 months and older) 1. Book your appointment & complete our pre-booking consent form. Wait 15 minutes after your vaccination in nearby car-park. endobj

Influenza Surveillance Report (FluView), Past Flu Seasons Flu Forecasting Accuracy Results, Tools to Prepare Your Practice for Flu Season, Information for Clinicians on Influenza Virus Testing, Multiplex Assays Authorized for Simultaneous Detection of Influenza Viruses and SARS-CoV-2, Information on Collection of Respiratory Specimens for Influenza Virus Testing, Information for Clinicians on Rapid Diagnostic Testing for Influenza, Information on Rapid Molecular Assays, RT-PCR, and other Molecular Assays for Diagnosis of Influenza Virus Infection, Algorithm: Interpreting Influenza Testing Results When Influenza is Circulating, Algorithm: Interpreting Influenza Testing Results When Influenza is NOT Circulating, Guide: Influenza Diagnostic Testing in Closed Setting Outbreaks, Guidance: Standard-Based Electronic Laboratory Reporting, Guidance: Antiviral and Obstetric Health Care, Guidance: Outbreak Management in Long-Term Care Facilities, Guidance: Use of Mask to Control Influenza Transmission, Guidance: Prevention & Control in Peri- and Postpartum Settings, Health Professional References & Resources, U.S. Department of Health & Human Services.
(Note: FERPA and HIPAA issues are discussed below under “Legal Issues”). Influenza/Pneumococcal Immunization Consent Form Influenza Consent I have read,or hadexplainedto me, the Vaccine Information Statement about influenza vaccination. Vaccine Information Statements (VISs) are information sheets produced by the CDC that explain to vaccine recipients, their parents, or their legal representatives both the benefits and risks of a vaccine. endstream endobj 269 0 obj <>stream The following are examples of authorizations that could be sought by SLV program planners including a statement with a request for a parental signature on the consent form: The entity conducting the vaccination program is responsible for only using and disclosing a child’s health information consistent with applicable laws. 268 0 obj <>stream
The first template consent form is designed for the injectable formulation of the vaccine, the second template consent form is designed for the intranasal formulation of the vaccine, and the third form is designed for both the injectable and the intranasal formulations.

Instead, requirements for informed consent are legislated or regulated by each state or jurisdiction, including the circumstances under which minors can consent to their own medical treatment. (Details to follow). Symptoms should resolve quickly – but speak to your medical practitioner if you experience long-lasting side effects, or more serious issues like difficulty breathing, hoarseness, swelling, hives, dizziness, or a fast heartbeat, as these can be signs of an allergic reaction or other unusual complication. But even if you’re late, the CDC still recommends getting vaccinated. The following are suggestions on the development of materials that should be delivered — via the child, mail, and/or email — to parents/guardians to inform them of the planned SLV clinic and solicit their permission to vaccinate their child. It should be signed by the patient, or, in the case of a minor, by a parent or legal guardian. Planners also should consider whether state/local law would require separate consents for administration of each dose of a two dose vaccine series. If a second dose of influenza vaccine will be offered, additional information about influenza vaccination histories may need to be collected. an announcement that influenza vaccine will be offered at the school, along with the clinic date(s) for both doses (if a second-dose clinic is planned and dates are possible to determine). children aged 2-12 years old ( born after October 2007 but before October 2018). An appropriate VIS (depending on which formulation of influenza vaccine is being offered–inactivated, injectable formulation or live, attenuated intranasal formulation) should be included among materials provided to parents/guardians before and after vaccine administration. Consent: This section includes a statement and signature line for parents/guardians to consent to or decline vaccination on behalf of their child. h޴��n�8�_��

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