INFLUENZA VACCINE SCREENING AND CONSENT FORM
Date of Birth:
Are you sick today?
(If you are moderately or severely ill you should wait until you recover before getting the flu vaccine)
Do you have a severe (life-threatening) allergy to eggs?
(Egg protein is a component of the influenza vaccine)
Are you allergic to latex?
(Some brands of flu vaccine have caps made with latex which may cause allergic reactions in latex sensitive individuals)
Have you ever had Guillain-Barre syndrome?
(A rare nerve disorder that can cause paralysis)
Have you ever had a severe (life-threatening) allergic reaction to a previous
r This is the first time I have ever
allergic reaction: hives, rash that covers body, difficulty breathing, etc.
There are 2 forms of influenza vaccine. Please mark which one you would prefer:
r Nasal Mist
Recommended for healthy people 2 through 49 years of age who are not pregnant and do not have certain health conditions (***see note below)
***The following people should NOT receive the nasal mist:
* *Anyone who has taken an antiviral medication within the last 48 hours (Tamiflu, Relenza, Amantadine, Rimantadine)
* Anyone who has received a live vaccine within the last 28 days
* Anyone with anemia or other blood disorders
Live vaccines include: MMR, Varicella (chicken pox), Shingles, oral Typhoid, Yellow Fever
* Have muscle/nerve disorders (cerebral palsy) that can lead to breathing/swallowing problems
* People who have long-term health problems with:
* Anyone with an allergy to gentamicin, gelatin, or arginine
* Anyone in close contact of someone who requires care in a protected environment such as a
I, the undersigned, hereby consent to and request that vaccination be administered. I have been provided with a Vaccine Information Sheet (VIS). I have had the opportunity to ask questions and received the answers concerning the vaccination that I will be receiving. I hereby release, and agree to hold harmless, Margaret Mary Community Hospital, and their directors, officers, agents, employees and volunteers, and all other participating organizations from any and all liability which may arise. This release is also binding on my heirs and next of kin. I hereby authorize the Infection Control Committee at Margaret Mary Community Hospital to perform various serum tests on a sample of my blood in the event that a health care worker has accidentally been exposed to my blood or body fluids. I understand that the Hospital’s Notice of Privacy Practices provides information about how they may use and disclose protected health information about me. A copy is available by contacting the Privacy Officer.
(Parent or Guardian's signature required if child is 17 years or younger)
Inactivated Influenza Vaccine
administered intramuscularly in:
r 0.5 ml with Preservative F0658 FLUAD F2038 F0008
r 0.5 ml Preservative free F0656 FLUAD F0656 F0008
MEDIZINISCHE FAKULTÄT Klinik für Nuklearmedizin - Universitätsklinikum Aachen Klinik für Nuklearmedizin Direktor: Univ.-Prof. Dr. med. F. MottaghyTelefon: +49 (0)241 8088 735Telefax: +49 (0)241 8082 520 Nuklearmedizinische Diagnostik und Therapie Inhaltsverzeichnis Diagnostik : Skelettdiagnostik Entzündungs-/Tumordiagnostik Lymphsystem, SLN-Diagnostik Endokri
Linnaeus University Post-doctoral position in gamma-ray astrophysics On 1st January 2010, Linnaeus University opened its doors for the first time as Sweden’s newest university, the result of a merger between Kalmar University and Växjö University. Context of position The astroparticle physics group in the Faculty of Technology, Department of Physics and Electrical Engineering at