Section 1: Information about client to receive vaccine (Please Prin= t)

3D"Roxbury Section 1: Information about client to receive vaccine (Please Print)

Client̵= 7;s Name (Last)

(First)

(M.I.)=

Date of Bir= th

=

Month:       &nbs= p;    Day:           Year:

Mailing Add= ress:

Age:

Gender:

Male    <= span style=3D'mso-bookmark:Check1'>       &nbs= p; Female    <= span style=3D'mso-bookmark:Check2'>

City:<= /o:p>

State:=

Zip Code:

Home Phone = #:

Parent/Guar= dian Name:

If applicabl= e

Relationshi= p to Client (Circle):

=

Self   Mother   Father<= span style=3D'mso-spacerun:yes'>   Legal Guardian   Foster Care

Aunt   Uncle   Grandmother    Grandfather

Municipalit= y (if

different fr= om mailing address):

Section 2: Screening

A. If your child has already been vaccinated with 2009 H1N1 influenza vaccine, please provide the following information (for age 10 years and younger only):

Form: Nasal Spray     Shot       Date Received: Month _____________ Day ______   Year ___________

B.     The fo= llowing questions will help us to know if you can get the 2009 H1N1 influenza vaccine. Please mark YES or N= O for each question.

=

YES

NO

1. Doe= s the person named above have a serious allergy to eggs or to a component of the vaccine?

<= span style=3D'mso-bookmark:Check5'>

<= span style=3D'mso-bookmark:Check6'>

2. Is = the person to be vaccinated sick today or has he/she been sick in the past 24 hours?

<= span style=3D'mso-bookmark:Check7'>

<= span style=3D'mso-bookmark:Check8'>       &nbs= p;

3. Has= the person named above ever had a serious reaction to a previous dose of flu vaccine?

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<= ![if !supportNestedAnchors]>=        &nbs= p;

4. Has= the person named above ever had Guillain-Barre Syndrome (a type of severe muscle

   &= nbsp; weakness) within 6 weeks after receiving a flu vaccine?

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<= ![if !supportNestedAnchors]>=        &nbs= p;

Section 3: Consent for Vaccination

I have read or had explained to me the 2009-2010 Vacci= ne Information Statement for 2009 H1N1 influenza vaccine and understand the ri= sks and benefits.

I GIVE CONSENT to the STATE/LOCAL health department an= d its staff to administer this vaccine to me or, if the name appearing above is a minor, to this individual as his her parent/legal guardian. I also consent = to having this data recorded recorded in the NJIIS (New Jersey Immunization Information System).

Signature (se= lf if 18 years or older, parent/legal guardian if child is under 18 years of age)

        =

        =             &nb= sp; ___________________________________________     Date: Month              Day             2009

Section 4: Vaccination Record   For Administrative Use Only

Vaccine

=

Date Given<= o:p>

Route IM

Staff =

Initial

Dose

Vaccine

Manufacture= r

   Lot= Number

2009 H1N1

=

R       <= ![if !supportNestedAnchors]>=       L      <= ![if !supportNestedAnchors]>=

Arm <= ![if !supportNestedAnchors]>=       Leg= <= ![if !supportNestedAnchors]>=

=

1^st<= ![if !supportNestedAnchors]>=

2^nd<= ![if !supportNestedAnchors]>=

=

=

Client̵= 7;s Name (Last)	(First)	(M.I.)=	Date of Bir= th = Month: &nbs= p; Day: Year:
Mailing Add= ress:	Age:	Gender: Male <= span style=3D'mso-bookmark:Check1'> &nbs= p; Female <= span style=3D'mso-bookmark:Check2'>
City:<= /o:p>	State:=	Zip Code:	Home Phone = #:
Parent/Guar= dian Name: If applicabl= e	Relationshi= p to Client (Circle): = Self Mother Father<= span style=3D'mso-spacerun:yes'> Legal Guardian Foster Care Aunt Uncle Grandmother Grandfather	Municipalit= y (if different fr= om mailing address):

=	YES	NO
1. Doe= s the person named above have a serious allergy to eggs or to a component of the vaccine?	<= span style=3D'mso-bookmark:Check5'>	<= span style=3D'mso-bookmark:Check6'>
2. Is = the person to be vaccinated sick today or has he/she been sick in the past 24 hours?	<= span style=3D'mso-bookmark:Check7'>	<= span style=3D'mso-bookmark:Check8'> &nbs= p;
3. Has= the person named above ever had a serious reaction to a previous dose of flu vaccine?	<= span style=3D'mso-bookmark:Check9'>	<= ![if !supportNestedAnchors]>= &nbs= p;
4. Has= the person named above ever had Guillain-Barre Syndrome (a type of severe muscle &= nbsp; weakness) within 6 weeks after receiving a flu vaccine?	<= ![if !supportNestedAnchors]>=	<= ![if !supportNestedAnchors]>= &nbs= p;