Parent or Guardian Please Complete This Portion
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|Municipality of Anchorage – Anchorage Health Department |
|Influenza Screening and Consent Form |
|First Name: Middle Initial: Last Name: |
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|Birth Date (month/day/year): Age: Gender: Primary Language: |
|English Other:_______________ |
|Race (Select all that apply): White Black/ African American Asian Ethnicity: |
|Alaskan Native American Indian Pacific Islander/Hawaiian Other: ________________ Hispanic Non-Hispanic |
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|Mailing Address: City: State: Zip: |
|Physical Address: City: State: Zip:|
|Same as above |
|Telephone – Circle: Home, Cell, or Wok Is it ok to text with immunization reminders? |
|( ) Yes No |
|Marital Status: Family Size (# of people that share income) Annual Income |
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|Single Married |
|Parent/Guardian Name and Relationship to minor (If Applicable): Parent/Guardian Birth Date (If Applicable): |
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|Are you sick today with something more than a minor illness? |πYES |πNO |
|Do you have allergies to medications, food, a vaccine component, or latex? |π YES |π NO |
|Have you ever had a serious reaction after receiving a vaccination? |π YES |π NO |
|Have you been diagnosed with Guillain-Barré Syndrome (a type of temporary severe muscle weakness)? |π YES |π NO |
|The Public Health Nurse will review any yes answers to determine if you should not receive any vaccine today. |
|If you have a concern regarding vaccines and a medical condition not listed above, please discuss with the Nurse. |
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|What type of medical insurance do you have? (select all that apply) |
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|π Private insurance that covers vaccines πMedicaid or Medicare |
|π Private insurance that does not cover vaccines πOther insurance |
|π No medical insurance πNo medical insurance |
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|πMedicaid/Denali Kid Care |
|πAlaska Native/American Indian |
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|Consent: |
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|The Municipality of Anchorage HIPAA privacy practices and HITECH Act practices document and the Municipality of Anchorage treatment consent form has been made available |
|for me to read. The most current Vaccine Information Sheet (VIS) has been made available for me to read. I understand their contents, and hereby consent to receive (or for|
|my child to receive) medical and related services. YES, I authorize the review and administration of this vaccine to be documented into VacTrAK, a vaccine record system |
|managed by the State of Alaska, Department of Health and Social Services, Section of Epidemiology. |
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|Client (or parent/guardian) Print Name: |
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|Client (or parent/guardian) Signature: Date |
|THIS SIDE IS FOR NURSE USE ONLY |
|Vaccination Record |
|Child: 18 years old and under |Adult: 19 years old and over |
|Eligibility |Funding Source |Eligibility |Funding Source |
| | | | |
|Circle one of the following: | |Circle one of the following: |Circle one of the following: |
|AVAP | |AVAP |STATE |
|VFC underinsured | | | |
|VFC uninsured |STATE | |PRIVATE |
|VFC Medicaid eligible | |Ineligible | |
|VFC AK Native/ American Indian | | | |
|Vaccine: |
| | | |
|State Supply: | |Fluarix Quadrivalent: preservative-free, latex-free, pre-filled syringe |
|VFC or AVAP | |Manufacturer: GlaxoSmithKline |
| | |Lot Number: 7AR35 Expires: 06-30-2020 Amount: 0.5mL (single dose) |
| | | |
|Private Supply: | |Flucelavax Quadrivalent: preservative-free, pre-filled syringe |
|Ineligible | |Manufacturer: Seqirus |
| | |Lot Number: 259811 Expires: 05-31-2019 Amount: 0.5mL (single dose) |
|ADMINISTRATION: | |
| | | | |
|Date Vaccine Administered |Route and Anatomical Site |Vaccinator’s Name & Provider # |VIS Date |
| |IM - Right Deltoid | | |
| |IM - Left Deltoid | |Inactivated Influenza |
| |IM - Right Anterolateral Thigh | |Vaccine |
| |IM - Left Anterolateral Thigh | | |
| | | |8-15-2019 |
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Screening Questions:
Children Only (18 and under)
Adults Only (19 and over)
Event Name/Location: _________________________
SHOULD THIS CHILD RECEIVE A SECOND DOSE?
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