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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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