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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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