Www.smscwellness.org
2020-2021 Influenza Vaccine [pic]
(IM Form)
Information about Individual to Receive Vaccine (Please Print)
|NAME (Last) |(First) |(Previous Last Name) |(M.I.) |MOTHERS MAIDEN NAME (LAST) |
|RACE |SEX: M F |DATE OF BIRTH |AGE |
| | |Month_______ Day______ Year ___________ | |
|ADDRESS |CITY |STATE |ZIP |DAYTIME PHONE NUMBER |
|EMPLOYER |Name of SMSC Employee: |Relation to Employee (please circle one): |
| | |Self Spouse Dependent |
Screening for Vaccine Eligibility
|The answers to the following questions will help us to determine if you can get the 2020-2021 influenza vaccine. |YES |NO |
|Please mark YES or NO for each question. | | |
|1. Did you receive a flu shot last year? | | |
|2. Are you ill today? | | |
|3. Do you have a serious allergy to eggs? | | |
|4. Do you have any other serious allergies? | | |
|Please list: ___________________________________________ | | |
|5. Have you ever had a serious reaction to a previous dose of influenza vaccine? | | |
|6. Have you ever had Guillain-Barré Syndrome? | | |
|(Guillain-Barré Syndrome is a type of temporary severe muscle weakness) | | |
|7. Are you age 65 years or older? | | |
|CONSENT FOR VACCINATION: |
| I GIVE CONSENT to be vaccinated with the 2020-2021 influenza vaccine. I have received the Vaccine Information Statement for the influenza vaccine and |
|understand the risks and benefits. |
|I understand that the information contained within this record is being maintained to monitor immunization needs in order to prevent disease. This information is|
|confidential and will only be shared with organizations or persons who are authorized by law to receive it. This includes the Minnesota Department of Health, a |
|health care provider or health care organization providing services on your behalf. |
|Signature of person receiving vaccine or Parent/Legal Guardian: |
| |
|Sign: _____________________________________________________ Date: ___________________________ |
|(Vaccination will not be administered if this consent form is not signed and dated.) |
FOR ADMINISTRATIVE USE ONLY
|Vaccine |Date Administered/ |Route |
| |VIS Given | |
EHR____________ MIIC_____________
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