influenza vaccine consent form 2020

These resources are designed to help prevent and manage the spread of Influenza like-illness (ILI) and seasonal Influenza. Keep informed about the latest on Alberta's Influenza Immunization program. For the 2020-2021 Influenza Immunization Program all community providers are required to complete the Influenza Program Registration Form. endstream endobj 200 0 obj <. I have read and understood the information provided and consent to have an influenza vaccination. Because the idea of vaccinating children at school may be unfamiliar to some parents/guardians, there may be reluctance to consent to influenza vaccination at school. Thank you from the Atrium Health Teammate Health for receiving your vaccination for the 2020 influenza season. Influenza Vaccination Consent form 2020 History ... • The influenza vaccine does not protect against other respiratory viruses such as the common cold. The National Immunisation Advisory Committee has updated the Influenza Chapter (Chapter 11) in their Immunisation Guidelines for Ireland. YES ☐ NO ☐ 4. Influenza Vaccine Consent Form (6 months and older) 1. Assessing the Need for Additional Precautions: For any questions regarding the Influenza Immunization Program, email Alberta Health, at. %PDF-1.6 %�� h��=JCA��i\�n@Ac~DH�$�e Detailed information related to the influenza vaccines used as part of the Alberta Influenza Immunization Programs are located on the AHS Immunization Program Standards Manual home page under “Biological Product Information”. 1. In the U.S., children are vaccinated primarily in their pediatrician’s or family doctor’s office (Groom, 2007). COVID SCREENING AND HEALTH INFORMATION This document assumes that pharmacies/pharmacists providing seasonal influenza immunizations already meet their jurisdictional regulatory requirements to do so. 2020-2021 Influenza Vaccine Consent Form NAME:_____DOB:_____ I understand that there is a possibility of complications occurring whenever an injection is received, including, but not limited to, allergic reactions and infections. Some people may not accept the use of porcine gelatine in medical products. Information about flu vaccine delivery for the 2020/2021 season Update from the National Immunisation Advisory Committee. This registration form provides the basic information needed to provide your site with influenza vaccine. Consent Details: Thank you from the Atrium Health Teammate Health for receiving your vaccination for the 2020 influenza season. 350 0 obj <>/Filter/FlateDecode/ID[<1E6B9770A788AD43881749A8CEB8203C><69D76071A5556A45A7670C0C288D679F>]/Index[199 223]/Info 198 0 R/Length 297/Prev 857395/Root 200 0 R/Size 422/Type/XRef/W[1 3 1]>>stream The below documents contain important information for community providers implementing a safe and effective influenza immunization program for 2020-2021. 2020-2021 Seasonal Influenza (Flu) Vaccine Consent Form . Patient Full Name Address Emergency Contact Emergency Contact Phone Number Physician/ Nurse Practitioner _____ Physician/NP Phone Number _____ 2. This is because it is considered better at reducing the spread of flu to others and is easier to administer. endstream endobj startxref I give my consent, voluntarily and of my own free will to the staff of St. Norbert College (SNC) Health Services Department to give me named above the Influenza Vaccine. 421 0 obj <>stream Patient Full Name Address Emergency Contact Emergency Contact Phone Number Physician/ Nurse Practitioner _____ Physician/NP Phone Number _____ 2. Before receiving the vaccine, you provided verbal consent to receive the vaccine and were able to ask questions about the vaccine. Influenza Immunization Consent Form: 2020 - 2021 Season. A flu shot (influenza) vaccine consent form is a written authorization that gives a nurse or other medical practitioner the go-ahead to administer the flu vaccine. This registration form provides the basic information needed to provide your site with influenza vaccine. Confirmation of program enrolment will occur when you receive the 2020-2021 Medical Officer of Health Influenza Immunization Program Letter. COVID SCREENING AND HEALTH INFORMATION Section 1: Patient Information . Information about the person getting vaccinated. It should be signed by the patient, or, in the case of a minor, by a parent or legal guardian. If your site cannot meet all recommendations outlined within this document please do not offer influenza vaccine to your patients or to members of the public. Note: “ Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices — United States, 2020-2021 Influenza Season” has been published. I have been given a copy of the Vaccine Information Funded influenza vaccines Please ensure you continue to have influenza vaccine stock available until 31 December for those who are eligible for influenza vaccination. I have read the Seasonal Influenza Vaccine Information Sheet and had a chance to ask questions which were answered to my satisfaction. Pharmasave West September 2020 AB/BC/MB/SK 1/2 2020/2021 INFLUENZA VACCINE CONSENT FORM . ��B�з� ��bʞF�W�5��i��|�~{߃�}[a�+�x��ע��{){��?�c�v��឵��]1�_��7p��n��{d^ÝT��sǁ��Nq��?�n�N2� 8'�=[�ᓣ��g��H8;O�em��S��_ 4�W� Have you ever previously been vaccinated against the flu? 1. 1. Date (MM/DD/YYYY): Last Name: First Name: Prov. h�b``��r��i�*`b�?Pn� �ĩP�� `��ؗ��=C�'�%{��@�g 7��!��9C�[�� @�mP��ۀ�=P�g$�w`y��@�G$��a��g1lڻ�ǔ��+C��|��X^�� E�E�y�-�buFQ��z�E��lg|#%�p�a��;V��L30��"��iy 8ʸ��t��~��x�:��/.w��l_��p��[W��5�k��bNn\|b2��^�>�v��VOߐ�2��+�:�\��/pʸyxi�#��N��'(�$ltra�Q0pp Z��1\�p�r1� Seasonal Influenza Vaccination Programme 2020/2021. 0 The parent or alternate decision-maker should. Before receiving the vaccine, you provided verbal consent to receive the vaccine and were able to ask questions about the vaccine. %%EOF ASSIGNMENT OF BENEFITS: I understand that all services, including unpaid balances, are charged to the responsible party. !H� �1b'�?��H��w��V6�3'�7�8Y'��xꥧ�:��1-W�� D��;Oiq��.�_8-��k�[�0ʯE� Vaccine Provider Registration Form Influenza Vaccine Provider Registration Form and Ordering. �@�* ` �� I give my consent, voluntarily and of my own free will to the staff of St. Norbert College (SNC) Health Services ... Department to give me named above the Influenza Vaccine. To the best of my knowledge, I do not have contraindications to the flu vaccine. It is offered because it is more effective in the programme than an injected vaccine. Thank you for helping keep our teammates, patients and community safe. COVID-19 info for Albertans & Health Professionals and about Family Support & Visitation. The AHS Vaccine Storage and Handling Standard contains detailed information and resources to assist in meeting the requirements for proper storage and handling of provincially funded vaccines. Policy Number Clinic/Office Site Where Vaccine Administered NYSIIS Permission ≥ 19 Years Old Doctor’s Address For Persons Under 19 Years Old, Mother’s Maiden Name Influenza/Pneumococcal Immunization Consent Form Influenza Consent I have read,or hadexplainedto me, the Vaccine Information Statement about influenza vaccination. Vaccine Storage and Handling is an important component of immunization programs. This letter will outline all aspects of the influenza immunization program for the 2020-2021 season. The following are the key changes: Read the updated Influenza Chapter from … Have you experienced any significant problems after previous flu vaccinations? YES ☐ NO ☐ 3. Please print clearly. One refund will be available for up to a total of 10 doses of unused AFLURIA ® QUAD and/or ten doses of INFLUVAC ® TETRA 2020 (Southern hemisphere formulation) and/or one dose of unused AFLURIA ® QUAD JUNIOR. For the 2020-2021 Influenza Immunization Program all community providers are required to complete the Influenza Program Registration Form. Consent Form 2020 Quadrivalent Influenza Vaccine Medical History Please answer the medical history questions below. Parents/guardians may seek the advice of others, including their child’s health care provider (Woodruff, 1996). I agree to wait in YES ☐ NO ☐ 2. For alternate decision-makers – please also send a copy of documents to show that you are authorized to be the alternate decision-maker. I understand the benefits and risks of the vaccine and willingly receive the vaccination. 199 0 obj <> endobj A copy of this vaccination is being sent to your Atrium Health medical record as a convenience and benefit to you and your Atrium Health provider to enrich your record of immunizations. The purpose of this document is to provide best practice suggestions and considerations for the delivery of seasonal influenza vaccine by community pharmacists in fall 2020. Health Number: Gender: Main Phone Number: Alternate Phone Number: Date of Birth (MM/DD/YYYY): Age: Child’s weight: (kg / lb) Address: City: Last Name First Name Middle Initial Date of Birth Age Street Address City State ZIP Code Phone Number Place a checkmark about the person getting vaccinated: Race: American Indian/Alsk. Are you allergic to the antibiotic’s neomycin, polymyxin or gentamycin? © Alberta Health Services 2020 Terms of UsePrivacy Statement, Canadian Immunization Guide Chapter on Influenza and Statement on Seasonal Influenza Vaccine for 2020-2021, National Advisory Committee on Immunization Statement on Thimerosal, Thimerosal Information for Nurses and Other Vaccine Providers, Oculorespiratory Syndrome (ORS) Algorithm, Directions for use of Influenza Immunization Vaccine Record, Influenza Reporting Requirements and Coding Explanations Document, Community Provider Administered Vaccine Monthly Report, Influenza Immunization for Pregnant Women, Breastfeeding Women and Families with Newborns, Influenza Immunization Aftercare and Client Immunization Record, Routine and Seasonal Immunization during COVID-19, Cover Your Cough poster – Emergency Departments, Cover Your Cough poster – Clinics and Offices, Guideline: Influenza Immunization for Adult and Pediatric Patients Undergoing Cancer Treatment, Influenza Outbreak in this Facility Poster (11 x 17), Influenza Outbreak in this Facility Poster (8.5x11), Influenza Outbreak Poster for Staff and Physicians (8.5x11), Q & A – Use of Antivirals in Acute Care and Continuing Care Settings, Practice Recommendations for Seasonal Influenza, Contact and Droplet Precautions Info Sheet, Guidelines for Outbreak Prevention, Control and Management in Acute Care and Facility Living Sites, Choosing Personal Protective Equipment (PPE) for Resident Interactions in Continuing Care, Seasonal Influenza in Continuing Care: IPC Practice Recommendations, Guidelines for Influenza Immunization in Adult and Pediatric Patients with Cancer, Guidelines for Outbreak Prevention, Management and Control in Emergency Shelters and Transitional Housing Sites, Guidelines for Outbreak Prevention, Control and Management in Supportive Living and Home Living Sites, Outbreak Guidelines: Acute Care & Facility Living Sites, Pneumococcal Polysaccharide Vaccine Biological Page, Alberta Health Influenza Immunization Policy (IIP), Influenza Immunization during Covid-19: Guidance for the 2020-21 Season, Influenza Immunization Health Professionals.

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