Pneumococcal Vaccine Consent Form

We are offering the pneumonia vaccine, Prevnar 20, to our residents based on the recommendations by the Centers for Disease Control (CDC This is usually a one-time vaccine.

As per the CDC, those recommended TO BE vaccinated include:

a) People who live in the nursing homes and other long-term care facilities b) People over 2 years of age with a weakened immune system c) People 65 years of age or older d) People 2 years of age or older who have a chronic illness such as heart, lung, kidney disease, sickle cell disease, diabetes, alcoholism, chronic liver diseases, or cerebrospinal fluid (CSF) leaks

Some people may need a booster and they include:

People age 65 and older who received the vaccine before age 65 if more than 5 years have passed. People who have received a transplant People with chronic kidney disease People with compromised immune systems (including those with HIV) People who need the booster should receive one at least five years after the first dose

Adverse drug events can occur as a result of the administration of the pneumonia vaccine. The most common adverse reactions can include but are not limited to swelling and soreness at the injection site. Some people experience fever and muscle pain.

YES, I would like the pneumonia vaccine to be given one time. I am aware of the adverse drug events/side effects of the vaccine. Should an adverse event/side effect(s) occur; I will not hold the facility responsible.

NO, I do NOT want the pneumonia vaccine administered.