ࡱ> []Z ,=bjbjT~T~ ;J66R bb   8A<} 1.     W$W$W$W1Y1Y1Y1Y1Y1Y1*35Y1]W$##|W$W$Y1   1K(K(K(W$j8  W1K(W$W1K(K(:?-,-  M/4Z $vk- C1101u-R67%6-6-|W$W$K(W$W$W$W$W$Y1Y1&W$W$W$1W$W$W$W$6W$W$W$W$W$W$W$W$W$b k: Annual Influenza Vaccine Consent Form-FLU SHOT Section 1: Information about Child to Receive Vaccine (please print) STUDENTS NAME (Last) (First)(M.I.)STUDENTS DATE OF BIRTH month_________ day________ year __________ PARENT/LEGAL GUARDIANS NAME (Last) (First)(M.I.)STUDENTS AGESTUDENTS GENDER M / FADDRESS PARENT/GUARDIAN DAYTIME PHONE NUMBER:CITYSTATE ZIPStudents Doctors Name (Last, First) Address City Zip SCHOOL NAMEHOMEROOM Teacher s NAMEGRADE Section 2: Screening for Vaccine Eligibility Was your child vaccinated with the seasonal influenza vaccine after July 1, 2010? YES m NO m The following questions will help us to know if your child can get the seasonal influenza vaccine. If you answer NO to all four of the following questions, your child can probably get the influenza vaccine. If you answer YES to one or more of the following four questions, your child may be able to get the seasonal influenza vaccine, but we will contact you to discuss your options. Please mark YES or NO for each question. YESNO1. Does your child have a serious allergy to eggs? m m 2. Does your child have any other serious allergies? Please list: _________________________________________________m m 3. Has your child ever had a serious reaction to a previous dose of flu vaccine?m m 4. Has your child ever had Guillain-Barr Syndrome (a type of temporary severe muscle weakness) within 6 weeks after receiving a flu vaccine? m m  Section 3: Consent CONSENT FOR CHILD S VACCINATION: I have read or had explained to me the 2010-2011 Vaccine Information Statement for the seasonal influenza vaccine and understand the risks and benefits. m I GIVE CONSENT to the NAME OF ORGANIZATION CONDUCTING CLINIC and its staff for my child named at the top of this form to be vaccinated with this vaccine. (If this consent form is not sig%./01<vwƼznnbnVJhWhH\5CJaJhXfh5CJaJhWhHxw5CJaJhWhC 5CJaJhWhC CJaJhWCJaJhWhCJaJhWh5CJaJh5h55>*CJaJh!hZ5>*h!hh85>*h5hZ5CJaJh5h5CJaJ h15hh5 h05 h]5 hY5 h05/0vw $$Ifa$gdXf $Ifgd  $IfgdWgdZ$a$gd     - > ULLL@LL $$Ifa$gdXf $Ifgdkd$$IfTl@\]$* t0644 laytWT     U V ^ _ e n w |  8 < ^ ` x ĹġГ~~~~rf[h15;CJaJhWhlt5CJaJhXfh05CJaJhW5CJaJhWh05CJaJhWh05;CJaJhXfhZ5CJaJhWhlb5CJaJhWhZCJaJhWhZ5CJaJhXfhH\5CJaJhWhH\CJaJhWhH\5CJaJhWhFw5CJaJ!> U V ^ _ 9kd$$IfTl@r]$!*p t0644 laytWT $Ifgd zqqqqq $Ifgdkd$$IfTl4@0]*G` t0644 laytWT ^ TK $Ifgdkde$$IfTl4@\]) $*   t0644 laytWT^ ` x $Ifgdpkd>$$IfTl@]*B- t0644 laytWT       + . 3 < F M ~sg[g[gOC7hWhO5CJaJhWhS{X5CJaJhWhc5CJaJhWhY5CJaJhWhC 5CJaJh5h5CJaJh!hUCJaJh!h*CJaJh!h,A}CJaJh5hU5>*CJaJh!h*5>*h!hh85>*h5hUCJaJhXfhlt5CJaJhWhlt5CJaJhWhlt5;CJaJhWhO[85;CJaJ   q hc^^YY^^Tgdec2gdUgdG^Ggdkd$$IfTl@F]o*/ t06    44 laytWT M p q  ƺyncncXMnByhXfhaCJaJhWh CJaJhWh0CJaJhWh^RCJaJhWhaCJaJhWCJaJhXfh*hWh(5>*hWhh85>*h5hYCJaJ#hWhYhYB*CJaJphhWB*CJaJphhWh0B*CJaJphhWhYB*CJaJphhWCJaJhXfhYCJaJhWhYCJaJl[OO $$Ifa$gdXfh$If^h`gdXfkd$$IflF'*/-'v t06    44 la ytHIlcWW $$Ifa$gdXf $Ifgdfv-kd$$IflF'*/-'v t06    44 la ytHILX8Z8lgbb[[[[[(gd*gdh8gdG^Gkdd$$IflF'*/-'v t06    44 la ytHI 8V8X8Z8`88889999b:d:f:r:t:;; ;Z;\;;;n<p<ԭԭ̖xl`UhXfhHICJaJhXfhHI5CJaJhS)hW5CJaJhS)hS)5CJaJh!h2q5h!h2q5>*hec2hW5CJaJhgh!CJ aJ h!hWh3_5CJaJ hWhn0h1CJaJhWh3_5 hWh3_hgh3_B*CJ aJ phUh!B*phhWh3_B*phned, then you child will not be vaccinated) m I DO NOT GIVE CONSENT to the NAME OF ORGANIZATION CONDUCTING CLINIC and its staff for my child named at the top of this form to be vaccinated with this vaccine. 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