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West Chester University Employee Vaccine Consent Form
|Name |SAP ID Number |
| | |
I have read and understand the Vaccine Information Statement(s) (VIS) dated 08/07/2015 for the influenza vaccine and have had any questions answered. I request that the vaccine checked below be given to me.
Signature _________________________________ Date ______________
IMMUNIZATION SCREENING QUESTIONNAIRE
|Are you sick today? |Yes |No |
|Do you have allergies to medications, food, a vaccine component or latex (including eggs)? | | |
| |Yes |No |
|Have you ever had a serious reaction after receiving a vaccine? |Yes |No |
|Have you had a seizure or brain or other nervous system problem? |Yes |No |
|***Flu vaccine: Have you ever had Guillain-Barre Syndrome? |Yes |No |
VACCINE |
DOSE |
EXT (circle) |
SITE |
ROUTE |MANUFACTURER/
LOT# |EXP DATE | |
Flucelvax
Quadrivalent
2018-2019 |
0.5 mL |Left
Right |
Deltoid |
IM |
Seqirus/252233 |
5/2019 | |
_________________________________________________ _______________________
Signature and Title of Vaccine Administrator Date
................
................
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