Influenza Vaccination Consent Form
Last Name:
First Name: Date of Birth:
Screening for influenza vaccine eligibility
1. Do you have a severe allergy to eggs? Yes No
2. Have you ever had a life-threatening reaction to the influenza vaccine? Yes No
3. Do you have a history of Guillain-Barre Syndrome? Yes No
4. Are you moderately or severely ill today? (fever >100.4F, cough, CoVid) Yes No
5. Are you pregnant? LMP: Yes No
If yes to any questions 1-3 then DO NOT vaccinate with influenza vaccine. If yes to question 4,
vaccinate when resident has recovered. If yes to question 5, must produce letter of consent from
current OB GYN.
I have read or had explained to me the Vaccination Information Statement about influenza vaccination
and I understand the benefits and risks of influenza vaccination. I request that the influenza vaccination
be given to me (or the person named above for whom I am authorized to make this request).
Signature: Date:
Name (print or type):
Employee No.
To be completed by person administering vaccine
Measured Temp:
Today's Date:
Site of Injection: R L Administered by: ________________
Expiration Date: December 2023
Lot No: AFLBA730AA
Influenza (Flu) Vaccine (Inactivated or
Recombinant): What you need to
know
1 dose each flu season.
It takes about 2 weeks for protection to develop after
Influenza vaccine can prevent influenza (flu). vaccination. There are many flu viruses, and they are
always changing. Each year a new flu vaccine is
Flu is a contagious disease that spreads around the
made to protect against three or four viruses that are
United States every year, usually between October
likely to cause disease in the upcoming flu season.
and May. Anyone can get the flu, but it is more
Even when the vaccine doesn’t exactly match these
dangerous for some people. Infants and young
viruses, it may still provide some protection.
children, people 65 years of age and older, pregnant
women, and people with certain health conditions or Influenza vaccine does not cause flu.
a weakened immune system are at greatest risk of flu
Influenza vaccine may be given at the same time as
complications.
other vaccines.
Pneumonia, bronchitis, sinus infections and ear
infections are examples of flu-related complications.
If you have a medical condition, such as heart
disease, cancer or diabetes, flu can make it worse.
Tell your vaccine provider if the person getting the
Flu can cause fever and chills, sore throat, muscle
vaccine:
aches, fatigue, cough, headache, and runny or stuffy
Has had an allergic reaction after a previous
nose. Some people may have vomiting and diarrhea,
dose of influenza vaccine, or has any severe,
though this is more common in children than adults.
life- threatening allergies.
Each year thousands of people in the United Has ever had Guillain-Barré Syndrome
States die from flu, and many more are (also called GBS).
hospitalized. Flu vaccine prevents millions of
In some cases, your health care provider may decide
illnesses and flu-related visits to the doctor each
to postpone influenza vaccination to a future visit.
year.
People with minor illnesses, such as a cold, may be
vaccinated. People who are moderately or severely ill
should usually wait until they recover before getting
CDC recommends everyone 6 months of age and influenza vaccine.
older get vaccinated every flu season. Children
6 months through 8 years of age may need 2 doses
during a single flu season. Everyone else needs
only
VACCINE INFORMATION STATEMENT
Soreness, redness, and swelling where shot is
given, fever, muscle aches, and headache can
happen after influenza vaccine.
There may be a very small increased risk of
Guillain-Barré Syndrome (GBS) after
inactivated influenza vaccine (the flu shot).
Young children who get the flu shot along with
pneumococcal vaccine (PCV13), and/or DTaP
vaccine at the same time might be slightly more
likely to have a seizure caused by fever. Tell
your health care provider if a child who is
getting flu vaccine has ever had a seizure.
People sometimes faint after medical procedures,
including vaccination. Tell your provider if you
feel dizzy or have vision changes or ringing in the
ears.
As with any medicine, there is a very remote
chance of a vaccine causing a severe allergic
reaction, other serious injury, or death.
An allergic reaction could occur after the vaccinated
person leaves the clinic. If you see signs of a
severe allergic reaction (hives, swelling of the face
and throat, difficulty breathing, a fast heartbeat,
dizziness, or weakness), call 9-1-1 and get the person
to the nearest hospital.
For other signs that concern you, call your health
care provider.
