IMMUNIZATION PROGRAM
Guidelines for Using the Influenza Vaccination
Administration Form for Health Care Workers
How to use this form:
You may want to use this form if you are participating in the FluSafe program because it contains the
required data elements for data entry into MIIC. If you modify this form or use a different form, please
make sure it includes the same data elements that are on Influenza Vaccination Screening Questionnaire
and Consent Form for Health Care Workers in order to accurately calculate vaccination rates for the
FluSafe program.
▪
▪
▪
▪
Use this form (or a similar one) for every health care worker that is vaccinated, even if they were
vaccinated outside your facility or they decline influenza vaccination.
Have the health care worker being vaccinated complete the entire form except for the
Administrative Use Only box.
▪ If the employee has been vaccinated outside your facility, they only need to fill in their
name, city and state of residence, date of birth, and the information in the first box
regarding previous vaccination.
▪ It is important for the person to fill in their date of birth as well as the city and state of their
residence to avoid duplicates of common names in MIIC.
The form also provides the person being vaccinated with information about the MIIC registry. If
they are not opposed to their immunization information being stored in the registry, no action is
required. However, if the person wants to opt out of the registry, they must call the number
listed.
Have the person administering the vaccine complete the Administrative Use Only box.
Note: By giving you this form, MDH is not providing you with any legal advice. If you have any legal
questions, you must ask your attorney.
Rationale for Flu Vaccination Screening Questions
1.
Are you sick today?
▪
▪
▪
2.
There is no evidence that acute illness reduces vaccine efficacy or increases vaccine adverse
events. However, persons who have moderate or severe illness should not be vaccinated until
their symptoms improve.
Minor illnesses, with or without fever, are not a contraindication to influenza vaccination.
Do not withhold vaccine if the person is taking antibiotics.
Do you have any life-threatening allergies?
▪
▪
▪
Allergic reactions to any component of the vaccine can occur.
People with egg allergies can safely get an influenza vaccine.
Always check the package insert for additional information on whether the allergen is a vaccine
component. Package inserts are available on the Immunization Action Coalition Food and Drug
Administration Product Approval: Vaccine index (www.immunize.org/fda/) page.
(10/2016) Page 1 of 2
GUIDELINES FOR USING THE INFLUENZA VACCINATION ADMINISTRATION FORM
FOR HEALTH CARE WORKERS
3.
Have you had a life-threatening reaction to influenza vaccine in the past?
▪
▪
▪
4.
Ask the person to describe the symptoms they experienced with a past influenza vaccination.
Immediate (presumably allergic) reactions are usually a contraindication to vaccination.
If the person experienced a local reaction to a prior vaccine dose or vaccine component, they
may still be vaccinated; this is not a contraindication to a subsequent dose.
If they experienced fever, malaise, myalgia, or another systemic symptom, it was likely due to
mild side effects from the vaccine, often more common after the first influenza vaccination; this
is not a contraindication.
Have you ever had Guillain-Barre (GBS) syndrome?
▪
As a precaution, persons who are not at high-risk for severe influenza complications and who
are known to have experienced GBS within 6 weeks of influenza vaccination generally should
not be vaccinated.
Completing the Administrative Use Only box
▪
▪
▪
If filled out completely, this form includes all data elements that are required under federal law
for documentation of vaccination. Thus, this consent form is a record of vaccination.
You may choose to modify this template to include the current VIS date and lot numbers of your
vaccine, so you won’t need to fill that in for each individual.
Please see tables for vaccine manufacturer codes and CPT codes. Most facilities will be able to
circle these on the form.
Vaccine manufacturer codes:
Protein Science = PSC
CSL = CSL
GlaxoSmithKline = SKB
Medimmune = MED
Seqirus = SEQ
Sanofi Pasteur = PMC
CPT Codes:
IIV3 (≥3 yrs) = 90658
IIV3, high-dose (>65years) = 90662
Intradermal p-free (18-64years) = 90630
IIV3, p-free (≥3 yrs) = 90656
IIV4 (≥3yrs)= 90688
IIV4 (6-35 months) = 90687
RIV3, p-free (≥18 yrs)= 90673
IIV3, 6-35 months = 90657
ccIIV4, p-free (≥4 yrs) = 90674
IIV4 p-free (>=3years) = 90686
IIV4, p-free (6-35mos) = 90685
Live Intranasal Quadrivalent = 90672*
aIIV3, adjuvanted (≥65 yrs)= 90653
*LAIV is not currently recommended for the 2016-17 influenza season.
Minnesota Department of Health
Immunization Program
PO Box 64975
St. Paul, MN
651-201-5503 or 1-800-657-3970
www.mdhflu.com
To obtain this information in a different format, call: 651-201-5503.
(10/2016) Page 2 of 2