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Octorara.k12.pa.us

Chester County Health Department School Influenza Vaccination Program
Dear Parent,
The Chester County Health Department will be offering the influenza vaccine to school students. The goal of this
program is to minimize absenteeism in the school and the community from influenza related illness. Influenza is a
very serious disease that strikes even healthy children. Health authorities are now recommending that all children,
ages 6 months to 18 years old, be vaccinated against influenza. There is no charge for the vaccine.
The vaccine will be administered by experienced Registered Nurses. The nurses will be offering both the influenza
nasal spray and the influenza shot at the school. Please complete the questionnaire on the back, which will help the
nurse determine what type of flu vaccine your child will receive. If a question is not clear, please call 610-344-
6252.
In order to participate in this program, please fill out this form completely for your child and return it to
your child’s school nurse.
CHILD’S INFORMATION:

____________________________________ ___________________________ _________
Last Name
_____________________________________________ _________ ______ _______/_______/_______ Address Apt/Suite Age Month Day Year
Date of Birth

______________________________________ _______ __________ (________) ________-_________
City
Parent email address:__________________________________________________
PLEASE CIRCLE

Gender:
Ethnicity: Non Hispanic Hispanic Unknown
Health Plan:
Private Insurance (Name_________________________)
PARENT or GUARDIAN CONSENT:

I give permission for my child to receive the influenza vaccine at the school for free. I have
answered the screening questionnaire and received a copy of the Vaccine Information Sheet.
Parent/Guardian (please print): Last _________________________ First __________________ Parent/Guardian Signature: ____________________________________ Date_______________ Relationship to child: (please circle) Mother Screening Questionnaire for Influenza Vaccination
1. Does your child have an allergy to eggs? 2. Does your child have an allergy to Gentamycin, latex, gelatin or thimerosal? 3. Has your child ever had a serious reaction to an influenza vaccine? 4. Has your child ever had Guillain-Barré Syndrome? 5. Does your child have asthma or a seizure disorder? Has your child ever had a health problem with lung disease, heart disease, kidney disease, metabolic disease (e.g. diabetes), a blood disorder or is currently receiving aspirin therapy? 7. Does your child have cancer, leukemia, AIDS or any other immune system problem? Has your child taken cortisone, prednisone, other steroids, or anticancer drugs, or had radiation treatments (does not include x-rays) in the past 3 months? Has the child received a transfusion of blood or blood products or been given a medicine called immune (gamma) globulin in the past year? Is your child/teen pregnant or is there a chance she could become pregnant during the next In the past four (4) weeks has your child received a MMR, Varicella (chickenpox), Yellow
Does your child have close contact with anyone who has a weakened immune system who is in
the hospital in a protective environment (e.g. an individual who has had a bone marrow
Please describe: _____________________________________________________ FOR CLINIC/OFFICE USE ONLY
Are you sick today? Yes or No
Date Vaccine Administered: ______/______/_________ s:\healthphs\general\iap\flu\flu 2012\flu 2012\2012 flumist school.doc

Source: http://octorara.k12.pa.us/cms/lib07/PA01916570/Centricity/Domain/39/influenze_consent_form.pdf

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