PERMISSION TO RECEIVE THE H1N1 INFLUENZA VACCINE



PERMISSION TO RECEIVE THE H1N1 INFLUENZA VACCINE

As you may have heard, a new influenza virus, called the 2009 H1N1 influenza virus, was first identified in the United States in late April 2009. The virus has caused illness ranging from mild to severe, including hospitalizations and deaths in adults and children.

The seasonal flu vaccine and the H1N1 flu vaccine are separate vaccinations. A seasonal vaccine is distributed routinely every year, the H1N1 flu vaccine has been developed and produced for the 2009 flu season.

The seasonal vaccine is not expected to protect against the H1N1 flu and the H1N1 flu vaccine is not intended to replace the seasonal flu vaccine. Each protects against a different virus and is intended to be used along-side the other.

Individuals are encouraged to get both vaccines as soon as possible.

In order to receive the H1N1 vaccine a separate permission slip must be signed. Please read and sign below:

Date: _______________

“I have read or have had explained to me the 2009-2010 Vaccine Information Statement (VIS) and understand the risks and benefits for the: (Check one box)

( ) 2009-2010 Inactivated H1N1 influenza vaccine, (VIS dated 10/2/09)

( ) 2009-2010 Live, Intranasal H1N1 influenza vaccine, (VIS dated 10/2/09)

Print name of person receiving vaccine.______________________________________

X____________________________________________________________________________

(Signature of person to receive vaccine or person authorized to make the request (representative or legal guardian)

Resident _____________ Staff ______________

FOR FACILITY USE ONLY

Date: __________________

Vaccine Manufacturer:______________________________

Vaccine Lot ___________________________

Expiration Date:____________________________

Injection Site:_______________________________________________

Signature and Title of Provider: ___________________________________________________

NOTES: ____________________________________________________________________________________________________________________________________________________________

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