Flu Vaccine Administration Form

Flu vaccine screening questions:*

Rows	Yes	No
Do you have any serious allergies?
Have you had a serious reaction to influenza vaccines?
Have you ever had Guillain-Barre Syndrome?
Are you sick today?

I consent to the vaccine.I am not able to receive the flu vaccination due to permanent contra-indication listed above.I am eligible for the flu shot, but do not wish to have the influenza vaccination given to me. I realize that my refusal may put patients, visitors, family and myself at risk for contracting the flu. Regardless, No, I do not wish to have the influenza vaccine given to me. Please check all of the following that apply:
Fear of the side effectsFear of injectionFear of getting influenza from the vaccineI just don't want the vaccineOther
Please list any serious allergies.
I understand that occasional reactions may occur and these may include, soreness at the injection site, fever and aches, and in rare cases a serious allergic reaction may occur. Signs of serious allergic reaction may include difficulty breathing, wheezing hives, dizziness, and fast heart rate. Should these symptoms arise seek medical attention. I have read the above information and been given a Vaccine Information Sheet. I've had the opportunity to ask questions.
Employee Signature*

Clear
Date*

MonthDayYear
Date
Employee Health Nurse
Manufacturer: Sanofi Pasteur Inc.

Expiration Date: 06/30/2024

Name and title of Vaccine Administration: Kelly Hobson, Employee Health Nurse
Date

MonthDayYear
Date
RightLeft
Lot#
EH Nurse Signature

Clear
Should be Empty:

Employee Health Nurse