Entities subject to the HIPAA Privacy Rule may use or disclose a minor’s health information with the signed authorization of the parent or a guardian with authority to make health care decisions for the child using a form that meets HIPAA requirements or without such authorization for treatment purposes and certain public health and other purposes. It should be completed in conjunction with a conversation between the patient and medical provider. 1 0 obj Linking to a non-federal website does not constitute an endorsement by CDC or any of its employees of the sponsors or the information and products presented on the website. (Note: FERPA and HIPAA issues are discussed below under “Legal Issues”). 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. The benefits of such a procedure, if determined to be legally viable and feasible in the jurisdiction that will be offering influenza SLV clinics, are that vaccine may be expeditiously given to consented children as soon as it is received by the vaccinator, and planners may be better able to plan for adequate staff, vaccine, and supplies. For maximum protection, get a flu shot early in the season. Related links to flu shot consent forms. To receive weekly email updates about Seasonal Flu, enter your email address: Centers for Disease Control and Prevention. The Centers for Disease Control and Prevention (CDC) cannot attest to the accuracy of a non-federal website. Wait 15 minutes after your vaccination in nearby car-park. Side effects are usually minor. An appropriate VIS (depending on which formulation of influenza vaccine is being offered–inactivated, injectable formulation or live, attenuated intranasal formulation) should be included among materials provided to parents/guardians before and after vaccine administration. contact information in case parents/guardians have questions or concerns. Title: VNA-SLU Flu Shot Consent and Insurance Form 2020 NEW Author: Anne Marie Created Date: 10/8/2020 7:54:57 PM endstream endobj 270 0 obj <>stream cdc flu vaccine consent form 2019-2020. influenza vaccine consent form 2019. flu vaccine consent form for employees. The release of information to public health authorities (e.g., for entry into an immunization registry for influenza reporting requirements), The release of information to the child’s health care provider (e.g., for inclusion in the child’s health care record). )���)KK�RY�����Zlg` xP 2 0 obj I have hada chance to ask questions, which were answered to my satisfaction, and I understand the benefits and risks of the Typically, this letter is sent out as a cover letter to accompany other materials, including the consent form, information about the vaccine, and when the SLV clinics are scheduled to occur. Standard practice is to get vaccinated yearly. �I�|�S�MDަ���f:��o�3�h��Ͷq��eQ�rH~�A� #B.#"?x�c"$�#���p!�'"���,"� �D@�x���~@޽�����t��~��e�n8���U�3����c"�0�+ m��t� �>�b�Ӱ�G����M�J�^����Փ�I�m�dI�~~��V�yRr�c0.h2���V�a�ظ�Ϸ�[V� Information about the person getting vaccinated. close or household contacts of the medically at risk group*. (Details to follow). Because the idea of vaccinating children at school may be unfamiliar to some parents/guardians, there may be reluctance to consent to influenza vaccination at school. Flu Vaccine (nasal spray) available for all children aged 2-12 years old from late October 2020 onward. To document their consent decision, parents would also need be given an appropriate consent form to complete and return to the school (see Template Consent Form for Use With Intramuscular, Injectable Formulation of Vaccine, Template Consent Form for Use with Live, Attenuated, Intranasal Formulation of Vaccine, and Template Consent Form for Use With Both the Intramuscular, Injectable Formulation and Live Attenuated, Intranasal Formulation of Vaccine). Below are notes about each section on the template consent forms: Information about child to receive vaccine: This section includes suggestions for collecting personal and demographic information. Planners also should consider whether state/local law would require separate consents for administration of each dose of a two dose vaccine series. x��7����S���C�t�U]՗�ǡ.õD�C��^kcC�#�J�)�x�%�������C��#����S ��Df"�@�i�߷����>v�ݰ�O����x�Ϸ/��۾�>|�nؾx�ݹ��^�fw;N������t�h6M����ŏ�_=��Z߾���}������_m����Ƀ�@��y `�7���?��郍V��G���}�ۏ�;���O��0�&�[����>�>���I��;�6%1_߀�b���F]�1�`w�`�OO�'���ƅw�d�`�a�|��ù��m�� }����ǟ}�t���|�ݝ������m�O�hsO�r)��p�L���ww��������5�2�LY�I_1���ͳ[&��~��~�)�}d���7hc�>��Fp��6��/�Z Among materials provided to parents/guardians should be a letter announcing that influenza SLV clinics will be offered at their child’s school. e�(�hbR�qH�*W��;�����M4$�̠i*}��{������̝քڸ�.�6 �(�db՗p ����Qw���`�ȧ^��;Ý��%���;�3�L�ޡ���;��:������՘Hj+���>`�#E� �:p��ҏj��GgP��nRV���T*cl`/Iݟ����0�. proof of flu shot form. If planning on obtaining advanced consent, planners should discuss this approach with state and local legal advisors before deciding to implement it. It’s quite likely that this year’s top strains will be different from last year’s, so it generally pays to get revaccinated. 8������������(Y�E������R��c���� Keeping providers informed about planned SLV clinics also will help them estimate how much influenza vaccine they will need to order for their own patients. If a second dose of influenza vaccine will be offered, additional information about influenza vaccination histories may need to be collected. Vaccination record: This section includes suggestions for collecting information regarding the vaccine and its administration. Peak viral activity can occur anytime from the fall through late winter or early spring. 3 0 obj �Q CDC is not responsible for Section 508 compliance (accessibility) on other federal or private website. The choice of which consent form(s) to distribute to parents/guardians will depend on which vaccine formulation (live-attenuated intranasal vaccine [LAIV], inactivated injectable vaccine, or both) will be offered at the SLV clinic. Information about the person getting vaccinated. These template consent forms can be modified to conform to state and local requirements. Please be aware that our agents are not licensed attorneys and cannot address legal questions. �����$��DbI�uRK�R+ D��bΥe��k�碕̱,n�™%������Rit�A�֩)\Y�]�d��o ��I� Consent Form 2020 Quadrivalent Influenza Vaccine Medical History Please answer the medical history questions below. As some influenza SLV programs do not offer second doses of influenza vaccine, these consent forms were developed for programs administering only one influenza vaccine to students. *ׄ�t�}�ׄ�e��w[u����>B�]�J�(�t�m?�|� g�ѩ�����Ίl�B�f��q��AD� ori���̋��. It should be signed by the patient, or, in the case of a minor, by a parent or legal guardian. As long as all questions on the form are answered truthfully, and the patient is given sufficient explanation of the associated risks, the form may provide the practitioner with some protection from liability. cdc flu consent form 2020. Book your appointment & complete our pre-booking consent form. Student information contained in the vaccine consent form may be protected by state or federal privacy laws or regulations. Flu vaccine cannot prevent all cases of flu, but it is the best defence against the disease. an announcement that influenza vaccine will be offered at the school, along with the clinic date(s) for both doses (if a second-dose clinic is planned and dates are possible to determine). Please provide a copy of this form to your physician and/or healthcare … This form includes a series of questions that can help to exclude patients who are at risk for complications and those who otherwise should not be vaccinated. endobj Saving Lives, Protecting People, Annual Influenza Vaccine Consent Form-FLU SHOT, Annual Influenza Vaccine Consent Form-NASAL SPRAY, Annual Influenza Vaccine Consent Form-FLU SHOT and NASAL SPRAY, Template Letters Seeking Advanced Consent for Vaccination, Centers for Disease Control and Prevention, National Center for Immunization and Respiratory Diseases (NCIRD), Reconstruction of the 1918 Influenza Pandemic Virus, 2019-2020 Preliminary In-Season Burden Estimate, Who is at High Risk for Flu Complications, Who Should & Who Should NOT Get Vaccinated, Live Attenuated Influenza Vaccine (LAIV)/Nasal Spray Vaccine, Selecting Viruses for the Seasonal Influenza Vaccine, Flu Vaccine and People with Egg Allergies, Frequently Asked Questions on Vaccine Supply, Historical Reference of Vaccine Doses Distributed, Hospitalized Adult Influenza Vaccine Effectiveness Network (HAIVEN), How Vaccine Effectiveness and Efficacy are Measured, What People with a Staph Infection Should Know about Flu, Resources for Hosting a Vaccination Clinic, Overview of Influenza Surveillance in the United States, Influenza Hospitalization Surveillance Network (FluSurv-NET), Weekly U.S. Instead, requirements for informed consent are legislated or regulated by each state or jurisdiction, including the circumstances under which minors can consent to their own medical treatment. Each of the following materials should be translated and available in various languages, as locally appropriate. Partnerships with organizations such as the American Association of Pediatricians and the American Academy of Family Physicians may also add to the success of the SLV program and assist in gaining support from local physicians. The nasal flu vaccine contains a highly processed form of gelatine derived from pigs (porcine gelatine). 4 0 obj State and local planners may consider distributing consent forms to parents in advance of influenza vaccine availability. If planners decide to pursue consent substantially in advance of the time that the vaccine is to be administered to the child , as described above, an informational packet also could be sent slightly in advance of the clinic (e.g., two or three weeks in advance).

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