St. Luke Catholic School at 1290 Nachreiner Avenue, Plain, WI 53577 US - H1N1 Consent Form
Section 1: Information about Child to Receive Vaccine (please print)
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STUDENT’S NAME (Last)
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(First)
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(M.I.)
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STUDENT’S DATE OF BIRTH
month_________ day________ year __________
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PARENT/LEGAL GUARDIAN’S NAME (Last)
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(First)
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(M.I.)
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STUDENT’S AGE
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STUDENT’S GENDER
M / F
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ADDRESS
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ETHNICITY (PLEASE CIRCLE)
Non-Hispanic Hispanic American Indian
Asian Black/African American White Other
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CITY
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STATE
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ZIP
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SCHOOL NAME
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GRADE
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Section 2: Screening for Vaccine Eligibility
If your child has already been vaccinated with 2009 H1N1 influenza vaccine, please tell us the number of doses and dates of vaccination.
? Dose 1 Date received: month ____day____year_______ Form (please circle): nasal spray shot
? Dose 2 Date received: month ____day____year_______ Form (please circle): nasal spray shot
The following questions will help us to know if your child can get the 2009 H1N1 influenza vaccine. Please mark YES or NO for each question.
If you answer “NO” to all three of the following questions, your child may get the influenza vaccine at school. If you answer “YES” to one or more of the following three questions or if your child is ill with a fever, your child will NOT get the influenza vaccine at school. Please contact your child’s medical provider or your local health department for H1N1 vaccination information. Please mark one box per question.
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YES
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NO
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1. Does your child have an allergy to eggs (including egg protein)?
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?
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?
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2. Has your child ever had a serious reaction to a previous dose of flu vaccine?
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?
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?
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3. Has your child ever had Guillain-Barré Syndrome (a type of temporary severe muscle weakness)?
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?
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?
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Section 3: Consent
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CONSENT FOR CHILD’S 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 for my child named at the top of this form to receive I DO NOT GIVE CONSENT
for my child Named at the top of this form to receive H1N1 flu vaccine at his/her school’s immunization clinic
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H1N1 flu vaccine at his/her school’s immunization clinic.
I DO / DO NOT (PLEASE CIRCLE ONE) give consent to share
immunization data in the Wisconsin Immunization Registry (WIR).
Signature of Parent/Legal Guardian: Signature of Parent/Legal Guardian:
________________________________________________________ ___________________________________________
Date: month______day______year___________ Date: month______day______year___________
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__________________________________________________________________________________
Section 4: Vaccination Record
FOR ADMINISTRATIVE USE ONLY
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Vaccine
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Date Dose Administered
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Route
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Dose Number
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Vaccine Manufacturer
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Lot Number
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Name and Title of Vaccine Administrator
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2009 H1N1
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/ /
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? IM
? Intranasal
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2009 H1N1
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/ /
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? IM
? Intranasal
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