Microsoft word - wccs h1n1 consent english.doc

Clark County Health Department
2009 H1N1 Influenza Vaccine Consent Form
Section 1: Information about Child to Receive Vaccine (please print)
STUDENT’S NAME (Last)
STUDENT’S DATE OF BIRTH
month_________ day________ year __________
PARENT/LEGAL GUARDIAN’S NAME (Last)
STUDENT’S AGE
STUDENT’S GENDER
PARENT/GUARDIAN DAYTIME PHONE
CITY STATE
SCHOOL NAME
Section 2: Screening for Vaccine Eligibility
If your child has already been vaccinated with 2009 H1N1 influenza vaccine, please tell us the number of doses and dates of vaccination.
 Dose 1 Date received: month ____day____year_______
 Dose 2 Date received: month ____day____year_______ The following questions will help us to know if your child can get the 2009 H1N1 influenza vaccine. Please mark YES or NO for each question.
A. 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 2009 H1N1 vaccine, but you will need to contact your private healthcare provider.
1. Does your child have a serious allergy to eggs? 2. Does your child have any other serious allergies? Please list: _________________________________________________ 3. Has your child ever had a serious reaction to a previous dose of flu vaccine? 4. Has your child ever had Guillain-Barré Syndrome (a type of temporary severe muscle weakness) within 6 weeks after B. There are two kinds of 2009 H1N1 influenza vaccine. Your answers to the following questions will help us know which of the two kinds of
vaccine your child can get.
1. Has your child gotten vaccinated with any vaccine (not just flu) within the past 30 days? Vaccine: ___________________________________ Date given: month______day_______year___________ 2. Does your child have any of the following: asthma, diabetes (or other type of metabolic disease), or disease of the lungs, heart, kidneys, liver, nerves, or blood? 3. Is your child on long-term aspirin or aspirin-containing therapy (for example, does your child take aspirin every day)? 4. Does your child have a weak immune system (for example, from HIV, cancer, or medications such as steroids or those used to 6. Does your child have close contact with a person who needs care in a protected environment (for example, someone who has Section 3: Consent
CONSENT FOR CHILD’S VACCINATION:
I have read or had explained to me the 2009-2010 Vaccine Information Statement for the 2009 H1N1 influenza vaccine and understand the risks and
benefits.
I GIVE CONSENT to the Clark County Health Dept or its designee I DO NOT GIVE CONSENT to the Clark County Health Department
and its for my child named at the top of this form to be vaccinated with staff for my child named at the top of this form to be vaccinated
this vaccine. with this vaccine.
(If this consent form is not signed, dated, and returned, then your child will
not be vaccinated at school)
Signature of Parent/Legal Guardian _____________________________ Signature of Parent/Legal Guardian____________________________
Date: month______day______year___________ Date: month______day______year___________
Section 4: Permission to Release Information
All vaccines administered will be entered into the Children and Hoosier Immunization Registry Program (CHIRP) by the Clark County Health
Department. By signing this release you are authorizing your childs vaccination record to be registered in CHIRP.
Section 5: Vaccination Record
FOR ADMINISTRATIVE USE ONLY
Vaccine Date
Dose Route Dose
Number Vaccine
Lot Number
Name and Title of Vaccine Administrator
Administered
(1st or 2nd)
Manufacturer
IMPORTANT H1N1 INFORMATION ATTACHED
Return of Consent Form REQUIRED
Please read the attached information and complete the attached
consent form as soon as possible. After completion please return
the form to your child’s school. Students should return the consent
form to your classroom teacher. Consent form is due back to
school by Monday, October 19.

This consent form is required regardless of whether or not you
want your child to receive the vaccination. You must answer all
questions for your child to receive the immunization. There is an
area to decline the vaccination if you wish to do so. There is no fee
for the vaccination.
Depending on the supply, the health department plans to give the
flu mist to elementary students that meet the medical criteria. We
follow the direction of the health department.
The letter from Dr. Burke, Health Officer from the Clark County
Health department provides information about the H1N1 virus as
well as the attached information sheet on the H1N1 flu shot.
When we know the date this immunization will be given at
your child’s specific school we will notify you again.

Parents may leave the signed permission slip at the school
office after your parent teacher conference.
2009 H1N1
INFLUENZAVACCINE
LIVE, ATTENUATED
W H A T Y O U N E E D T O K N O W
(the nasal spray vaccine)
Many Vaccine Information Statements are available in Spanish and other languages. See www.immunize.org/vis.
• They will not prevent seasonal fl u. You should also
What is 2009 H1N1 infl uenza?
get seasonal infl uenza vaccine, if you want
2009 H1N1 infl uenza (sometimes called Swine Flu) is protection from seasonal fl u.
caused by a new strain of infl uenza virus. It has spread to Live, attenuated intranasal vaccine (or LAIV) is
sprayed into the nose. This sheet describes the live,
Like other fl u viruses, 2009 H1N1 spreads from person attenuated intranasal vaccine.
to person through coughing, sneezing, and sometimes An inactivated vaccine is also available, which is given
through touching objects contaminated with the virus.
as a shot. It is described in a separate sheet.
The 2009 H1N1 LAIV does not contain thimerosal or other preservatives. It is licensed for people from 2 Some people also have diarrhea and vomiting. The vaccine virus is attenuated (weakened) so it will not Most people feel better within a week. But some people get pneumonia or other serious illnesses. Some people have to be hospitalized and some die.
Who should get 2009 H1N1
4 infl uenza vaccine and when?
How is 2009 H1N1 different
from regular (seasonal) fl u?
LAIV is approved for people from 2 through 49 years of Seasonal fl u viruses change from year to year, but they age who are not pregnant and do not have certain health conditions (see number 5 below). Groups recommended People who have had fl u infections in the past usually to receive 2009 H1N1 LAIV fi rst are healthy people who: have some immunity to seasonal fl u viruses (their • are from 2 through 24 years of age, bodies have built up some ability to fi ght off the viruses).
• are from 25 through 49 years of age and The 2009 H1N1 fl u virus is a new virus strain. It is very - live with or care for infants younger than 6 months of age, or - are health care or emergency medical personnel.
Most people have little or no immunity to 2009 H1N1 fl u (their bodies are not prepared to fi ght off the virus).
As more vaccine becomes available, other healthy 25 through 49 year olds should also be vaccinated. 3 2009 H1N1 infl uenza vaccine
Note: While certain groups should not get LAIV – for Vaccines are available to protect against 2009 H1N1 example pregnant women, people with long-term health problems, and children from 6 months to 2 years of age – it is important that they be vaccinated . They should get • These vaccines are made just like seasonal fl u The Federal government is providing this vaccine for • They are expected to be as safe and effective as receipt on a voluntary basis. However, state law or employers may require vaccination for certain persons.
• They will not prevent “infl uenza-like” illnesses Get vaccinated as soon as the vaccine is available.
Children through 9 years of age should get two doses of
Some adults 18-49 years of age have reported: vaccine, about a month apart. Older children and adults need Some people should not get
Severe problems:
5 the vaccine or should wait
• Life-threatening allergic reactions to vaccines are very rare. If they do occur, it is usually within a few minutes You should not get 2009 H1N1 LAIV if you have a severe
(life-threatening) allergy to eggs, or to any other substance
• In 1976, an earlier type of inactivated swine fl u vaccine was in the vaccine. Tell the person giving you the vaccine if you
associated with cases of Guillain-Barré Syndrome (GBS). 2009 H1N1 LAIV should not be given to the following groups. • children younger than 2 and adults 50 years and older What if there is a severe
7 reaction?
• anyone with a weakened immune system,• anyone with a long-term health problem such as What should I look for?
Any unusual condition, such as a high fever or behavior changes. Signs of a severe allergic reaction can include diffi culty breathing, hoarseness or wheezing, hives, paleness, • children younger than 5 years with asthma or one or more weakness, a fast heart beat or dizziness.
episodes of wheezing during the past year, What should I do?
• anyone with certain muscle or nerve disorders (such as • Call a doctor, or get the person to a doctor right away.
cerebral palsy) that can lead to breathing or swallowing • Tell the doctor what happened, the date and time it
happened, and when the vaccination was given.
• anyone in close contact with a person with a severely • Ask your provider to report the reaction by fi ling a Vaccine
weakened immune system (requiring care in a protected Adverse Event Reporting System (VAERS) form. Or you environment, such as a bone marrow transplant unit), fi le this report through the VAERS website at • children or adolescents on long-term aspirin treatment.
www.vaers.hhs.gov, or by calling 1-800-822-7967.
If you are moderately or severely ill, you might be advised to VAERS does not provide medical advice. wait until you recover before getting the vaccine. If you have a mild cold or other illness, there is usually no need to wait.
8 Vaccine injury compensation
Tell your doctor if you ever had:• a life-threatening allergic reaction after a dose of seasonal If you or your child has a reaction to the vaccine, your ability • Guillain-Barré syndrome (a severe paralytic illness also However, a federal program has been created to help pay for the medical care and other specifi c expenses of certain These may not be reasons to avoid the vaccine, but the persons who have a serious reaction to this vaccine. For more information about this program, call 1-888-275-4772 or visit
2009 H1N1 LAIV may be given at the same time as most other vaccines. Tell your doctor if you got any other vaccines within www.hrsa.gov/countermeasurescomp/default.htm.
the past month or plan to get any within the next month. H1N1 LAIV and seasonal LAIV should not be given together.
9 How can I learn more?
What are the risks from
• Ask your provider. They can give you the vaccine package 6 2009 H1N1 LAIV?
insert or suggest other sources of information.
• Call your local or state health department.
A vaccine, like any medicine, could cause a serious problem, • Contact the Centers for Disease Control and Prevention (CDC): such as a severe allergic reaction. But the risk of any vaccine 1-800-232-4636 (1-800-CDC-INFO) or
causing serious harm, or death, is extremely small.
- Visit CDC’s website at www.cdc.gov/h1n1fl u or
The risks from 2009 H1N1 LAIV are expected to be similar www.cdc.gov/fl u
Visit the web at www.fl u.gov
Mild problems:
Some children and adolescents 2-17 years of age have
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Disease Control and Prevention
reported mild reactions, including: • runny nose, nasal congestion or cough • fever • abdominal pain or occasional vomiting or diarrhea

Source: http://www.wclark.k12.in.us/uploads/file/SCE/H1N1%20Packet%205%20Pages%20(Nasal).pdf