INFLUENZA VACCINE RECORD
INFLUENZA VACCINE RECORD 2006 - 2007
The University of Chicago Hospitals
Occupational Medicine
| |
|PLEASE PRINT - Name: |
| |
|Department: Last 4 digits of SS#: |
( Hospital Employee ( BSD/University Employee ( UCH Volunteer
Yes No
( Are you allergic to eggs? ( (
( Are you ill with a fever greater than 100˚F? ( (
( Have you read the Influenza Vaccine information statement? ( (
( Have you ever had Guillain-Barré Syndrome? ( (
POSSIBLE ADVERSE EFFECTS:
( Soreness at site of injection for one to two days (somewhat common)
( Fever and achiness for one to two days (very rare)
( Life-threatening allergic reactions, usually in persons allergic to eggs (extremely rare)
( Guillain-Barré syndrome, an acute paralytic illness (extremely rare, if at all)
I have read or have had explained to me the information on the vaccine information statement about influenza vaccine. I have had a chance to ask questions, which were answered to my satisfaction. I understand the benefits and risks of the influenza vaccine and request that it be given to me.
Signature: _______________________________________
|UCOM staff only: |
| |
|Date Administered: _________________ Site (deltoid): R L |
| |
|Given by: ____________________________ |
| |
|Expiration date/lot number |
|(place sticker from dose here) |
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related download
- letter sonning common
- georgia department of public health
- information for aboriginal and department of
- information for aboriginal and department of health
- attachment product information for inactivated
- general questions and answers on 2009 h1n1 influenza
- vaccination columbia university
- influenza vaccine record
- sample adverse reaction guidelines policy and procedure
Related searches
- influenza vaccine products for 2019 2020
- influenza vaccine 2019 2020
- cdc influenza vaccine 2019
- cdc influenza vaccine 2019 2020
- influenza vaccine code 2019 medicare
- 2019 influenza vaccine cpt codes
- influenza vaccine 2019 2020 cpt codes
- influenza vaccine components 2019
- influenza vaccine sanofi pasteur
- sanofi influenza vaccine package insert
- sanofi pasteur influenza vaccine portfolio
- influenza vaccine fluzone quadrivalent