Purdue University Northwest



4140200-561976 00 52705047752000Occupational HealthSEASONAL INFLUENZA VACCINATION CONSENT FORM2020/2021**COMPLETE ALL INFORMATION REQUESTED ON THIS FORM**Name (PLEASE PRINT): DOB:If you have had recent chemotherapy, radiation therapy, or steroids (except inhaled), these conditions may decrease the effectiveness of the vaccine. However, influenza vaccination is still encouraged.Influenza vaccination is recommended for any woman who will be breastfeeding during the influenza season, or will be pregnant during the influenza season. Vaccination can occur in any trimester.YES NO FORMCHECKBOX FORMCHECKBOX 1.I have reviewed the CDC flu vaccine information statement and had my questions answered. FORMCHECKBOX FORMCHECKBOX 2.Are you allergic to eggs or egg products? FORMCHECKBOX FORMCHECKBOX 3.Are you allergic to thimerosal (a preservative) other than contact lens sensitivity? FORMCHECKBOX FORMCHECKBOX 4.Have you ever had Guillain-Barre Syndrome within 6 weeks of taking a flu shot? FORMCHECKBOX FORMCHECKBOX 5.Have you ever had an anaphylactic reaction to the influenza vaccine? FORMCHECKBOX FORMCHECKBOX 6.Are you allergic to latex? FORMCHECKBOX FORMCHECKBOX 7.Did you receive a flu shot last year?YES, I consent to have the influenza vaccine given to me.76835-19939000281305-199390007683544450076835-19939000I have been given and have read or have had explained to me, the information in the Vaccine Information Statement(s) for the Influenza Vaccine. I have had a chance to ask questions that were answered to my satisfaction. I understand the benefits and risks of the vaccine requested and ask that the vaccine be given to me.Signature: __________________________________________________Date: ______________6990080635000***Office Use Only***FLU VAXManufacturer: ____________________Lot # ______________________Exp. Date_________________Site:Left deltoidRight deltoidIntra-nasalDose: 0.5 ml /Other __Temperature:_(optional)____________________Signature:_________________________________________________RN/LPN/MA/RTDate: ____________________________________MP09/20122647950-1130300002736215-1130300002647950-1042035002647950-1130300004926330-1130300005014595-1130300004926330-1042035004926330-113030000553720-89598500641985-89598500553720-80708500553720-895985001532255-895985001620520-895985001532255-807085001532255-895985002445385-895985002533650-895985002445385-807085002445385-89598500-4445-129222500 ................
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