Section 1: Information About Person to Receive Vaccine (Please Print)

H1N1 Vaccine Consent Form, Page 1 of 2

Mecklenburg County Health Department

2009 H1N1 Influenza Vaccine Consent Form

Section 1: Information about Person to Receive Vaccine (please print)

Related health information on second page of this consent form.

Patient’s Last Name: / First Name: / (M.I.) / DATE OF BIRTH:__/___/___ AGE: ______
mo day year
GRADE:______GENDER: Male Female
If patient is a minor- PARENT/LEGAL GUARDIAN’s Last Name: / First Name: / (M.I.) / PARENT/GUARDIAN’S DAYTIME PHONE NUMBER:
ADDRESS: / DO YOU HAVE HEALTH INSURANCE? YES NO
Medicaid Medicare
(Enter # in boxes)
Private Ins. Company:______
CITY / STATE / ZIP
LOCATION OF CLINIC:NWHDSEHD Eastland WIC NW WIC OtherSchool SE WIC
Name of School/Other Site: ______ / Private Responsible Party:
______
Private Ins. Policy#:______

Section 2: Consent

CONSENT FOR VACCINATION:
I have read or had explained to me the 2009-2010 Vaccine Information Statement for the 2009 H1N1 influenza vaccine and understand the risks and benefits.
I GIVE CONSENT to the Mecklenburg County Health Department and its staffto administer the 2009 H1N1 influenza vaccine for the person named on this form.
I DO NOT GIVE CONSENT to the Mecklenburg County Health Department and its stafftoadminister the 2009 H1N1 influenza vaccine for the person named on this form.
My child has beenorwill be(circle appropriate option) vaccinated for the 2009 H1N1 influenza vaccine at my doctor’s office.
Signature of patient or guardian: ______Date: ______
AUTHORIZATION FOR ASSIGNMENT OF BENEFITS: I authorize the Mecklenburg County HealthDepartment to request and receive payment on my behalf for services covered by my insurance, Medicaid,Children’s Health Insurance Program and/or Medicare. I understand that my signature will serve as legal “Signatureon File” for purpose of filing my insurance claims and payment of medical benefits of Mecklenburg County Health Department for services rendered. I authorize the release of any medical information to process any claim.
Signature of patient or guardian: ______Date: ______

Section 3: Vaccination Record

FOR ADMINISTRATIVE USE ONLY

Vaccine / Date Dose
Administered / Route / Dose
1st or 2nd / Vaccine Manufacturer / Lot Number / Name, Title and Provider #
2009 H1N1 / / / /  IM
 Intranasal
2009 H1N1 / / / /  IM
 Intranasal

Mecklenburg County Health Department

H1N1 IMMUNIZATION ELIGIBILITY HEALTH QUESTIONS

To be answered as part of the H1N1 Vaccination Consent Form

Patient name: ______Date______

Person filling out Sections A & B: ______

Relationship to Patient______

The following questions will help us to know if youcan get the 2009 H1N1 influenza vaccine. There are two ways you may receive the 2009 H1N1 influenza vaccine, a shot or a nasal spray. Most people can get the shot, but only healthy people between the ages of 2-49 should get the nasal spray. Your answers to the following questions will help us know which of the two kinds of vaccine you may get. Please mark YES or NO for each questionin Sections A and B, only.

SECTION A (may be filled out in advance of the vaccination) / YES / NO

1. Does the person getting the vaccine have a serious allergy to eggs?

1. Does the person getting the vaccine have any other serious allergies? Please list:______

1. Has the person getting the vaccine ever had a serious reaction to a previous dose of flu vaccine?

1. Has the person getting the vaccine ever had Guillain-Barré Syndrome (a type of temporary severe muscle weakness) within 6 weeks after receiving a flu vaccine?

1. Has the person getting the vaccine today taken medicine to prevent or lessen the symptoms of flu in the past 48 hours (ex. Tamiflu, Relenza).

SECTION B (may be filled out in advance of the vaccination) / YES / NO

1. Has the person getting the vaccine been vaccinated with any vaccine (not just flu) within the past 30 days?

Name of Vaccine: ______
Date received: month______day______year______

1. Does the person getting the vaccine have any of the following: asthma, diabetes (or other type of metabolic disease), or disease of the lungs, heart, kidneys, liver, nerves, or blood?

1. Is the person getting the vaccine on long-term aspirin or aspirin-containing therapy (for example, take aspirin every day)?

1. Does the person getting the vaccine have a weak immune system (for example, from HIV, cancer, or medications such as steroids or those used to treat cancer)?

1. Is the person getting the vaccine pregnant?

1. Does the person getting the vaccine have close contact with a person who needs care in a protected environment (for example, someone who has recently had a bone marrow transplant)?

SECTION C (to be filled at the time of vaccination by health care professional) / YES / NO
Does the person getting the vaccine feel sick today (fever, cough, other?)
(For young children, this information must be provided by parent/guardian or assessed by health care professional if parents are not present.)

This form must be completed before the H1N1 vaccine may be administered.