DATE

CLINIC LOCATION

INFLUENZA VACCINE DOCUMENTATION AND CONSENT FORM

Birthdate M F

Phone

Employee ID

Name

Address

City, St, Zip

Employee Status Active Employee Retired Employee

Are you enrolled in a CPS Health Insurance Plan? YES NO

Have you ever had a severe allergic reaction to eggs? YES NO

Are you allergic to thimerosal (a preservative) other than contact lens sensitivity? YES NO

Have you ever had Guillain-Barre Syndrome or under care for a neurological disorder? YES NO

Have you ever had a reaction to the influenza vaccine? YES NO

Do you have sensitivity to latex? YES NO

Do you have a fever or any illness at this time? YES NO

Pregnant? Are you pregnant or attempting to become pregnant? YES NO A note from your doctor is required if you are in your first trimester

Patient Signature Date

THIS SECTION TO BE COMPLETED BY NURSE

Vaccine Temperature Check °F

Manufacturer COVID Screening Q&A YES NO

Lot Number Deltoid Site LEFT RIGHT

Expiration Date Reaction YES NO

Administered by Signature

2020-2021 Quadrilvalent Vaccine: A/Guangdong-Maonan/SWL1536/2019 (H1N1), A/HongKong/2671/2019 (H3N2), A/ Wisconsin/67/2005 ( H3N2); B/Washington/02/2019 (B Victoria lineage), B/Phuket/3073/2013 (B Yamagata lineage) B/Malaysia/2506/2004;

Risk and Possible Side EffectsInfluenza vaccine generally causes only mild side effects that occur at low frequency. Most commonly, the reactions may be sore or tender arm at the injection site, or possible fever, chills, headache or muscle aches. These effects usually last 24-48 hours. Most people who receive the vaccine either have no or mild reactions. There is a possibility, as with any vaccine or drug that an allergic or other serious reaction, even death, could occur. Moreover, untoward medical events completely unrelated to vaccine administration may occur coincidentally in the aftermath period following vaccination. Unlike the 1976 swine influenza vaccine, flu vaccines used subsequently have not been clearly associated with an increased frequency of Guillain-Barre’ syndrome, which is associated with paralysis. By signing below, I understand I am receiving the flu vaccine.

First Timer? YES NO If yes, please plan to wait at least 15 minutes after your shot for observation. Let the nurse if you have any concerns or reactions.