SCHOOL INFLUENZA (FLU) IMMUNIZATION CONSENT
SKIIP 2016-17
Public Health Division
For school office use: Place sticker/stamp w
If you would like the vaccine given at school, fill in this form completely and legibly, including complete insurance
information and return by ____________________ (date) to the school nurse
Student’s
legal last name: ____________________________ First name: ______________________________ Middle name: __________________
Mailing address: _____________________________________________________ Zip: __________ Daytime phone: ________________________
Birth Date: _____/______/______ Age:_____ Mother’s maiden (birth) name:__________________________________________________________
Month / day
/
year
first name and last name
School name: ______________________________________ Grade: _______ Teacher:_______________________ Student ID#:_______________
Race:
American Indian/Native American/Alaska Native
Asian
Other
Ethnicity:
Hispanic
Gender:
Male
Black/African American
Native Hawaiian/Pacific Islander
White
Non-Hispanic
Female
INSURANCE INFORMATION―Fill in appropriate category―REQUIRED
Medicaid/Centennial Care
Private/insurance
Member ID / Patient/Policy # _________________________________
No insurance/uninsured
Centennial Care (Medicaid) # _________________________________
Blue Cross Blue Shield
Molina Healthcare
Group (private insurance) # ___________________________________
United Healthcare
Presbyterian
Name of policyholder________________________ _______________
Other insurance: ________________________________________
Policyholder date of birth (insurance company name)
MEDICAL SCREENING QUESTIONS―REQUIRED
If you answer yes to either question 1, 2 or 3 below, your child cannot get vaccinated at school. Contact your child’s doctor for options.
NO YES
There are two types of flu vaccine available. If you answer yes to questions 4 through 11 below, your child may not be able to get the nasal spray
(live) vaccine, but may still be able to receive a flu shot if available. The nurse will assess eligibility based on the answers to these questions.
NO
Questions 12 and 13 help to determine if your child will need one or two doses of flu vaccine.
NO YES
1) Does your child have a severe allergy (difficulty breathing, swollen face/lips, recurring vomiting) to eggs or gentamicin sulfate? ..................
2) Does your child have hemophilia? ....................................................................................................................................................................
3) Has your child ever had a serious reaction to flu vaccine in the past, or developed Guillain-Barré syndrome
(a temporary severe muscle weakness)? .........................................................................................................................................................
4) Has your child had an asthma attack, a wheezing episode, or taken asthma medicine within the past 12 months? .......................................
5) Does your child have: Diabetes, disease of the heart, kidney, liver or lungs, seizures, anemia or other blood disorder,
neuromuscular disease, or cerebral palsy? ......................................................................................................................................................
6) Does your child have a severe allergy to latex or the food ingredients MSG, gelatin, or arginine? ..................................................................
7) Has your child received any vaccines in the past 4 weeks? ............................................................................................................................
If yes, which ones:____________________________ Date given________________________
8) Is your child on long-term aspirin therapy, for example, does your child take aspirin every day? ....................................................................
9) Does your child have a weakened immune system (for example, from HIV, cancer or medicines such a steroids or
those used to treat cancer)? .............................................................................................................................................................................
10) Does your child have close or direct contact with someone who is in a protected environment for an extremely weakened immune
system (for example, bone marrow transplant unit)? ........................................................................................................................................
11) Is your child pregnant? ......................................................................................................................................................................................
YES
12) Did your child receive the flu vaccine last season (2015-16)? ..........................................................................................................................
13) Has your child received at least two doses of the flu vaccine since July 2010? ...............................................................................................
CONSENT FOR CHILD’S VACCINATION IN SCHOOL
I have read or had explained to me information in the 2016-17 Intranasal Influenza Vaccine Information Statement and the 2016-17 Injectable Influenza
Vaccine Information Statement and understand the benefits and risks of influenza vaccine and request that the influenza vaccine be given to the person
above for whom I am authorized to make this request. If the person above for whom I am authorized to make this request is less than 9 years old and
it is determined that a 2nd dose is needed, I also consent for a 2nd dose of vaccine to be given if offered through the school. Unless I sign a
statement signifying otherwise, I allow immunization information to be entered into the New Mexico Statewide Immunization Information System (NMSIIS)
and be released to other medical care providers to avoid unnecessary vaccination or to ascertain immunization status. The DOH Privacy Policies are
available at http://nmhealth.org/help/privacy/ and will be given to all patients when they receive an immunization.
I will contact the school nurse to withdraw this consent if this child is immunized before the date of the school clinic.
Signature of parent/legal guardian________________________________________________________________Date__________________________
Print name of parent/legal guardian (print legibly in all caps)_________________________________________________________________________
For clinic use (this section must be completed by the medical provider) VIS date: 2016-17
Dose #1 VACCINE: 
MedImmune IIV Fluarix GSK Other __________ Lot #___________ exp. date______
Site of administration: Intranasal
R Deltoid
L Deltoid
Other________________
Date vaccinated:______________ Signature:___________________________________ _________________________________
FluMist®
Name and title of vaccine administrator
Preceptor name and credentials
Name and title of vaccine administrator
Preceptor name and credentials
VFC PIN#____________
Date NMSIIS data entry completed__________________
Dose #2 VACCINE: FluMist® MedImmune IIV Fluarix GSK Other __________ Lot #___________ exp. date______
R Deltoid
L Deltoid
Other________________
Site of administration: Intranasal
Date vaccinated:______________ Signature:___________________________________ _________________________________
VFC PIN#____________
Date NMSIIS data entry completed__________________
Required: Date VIS
given to patient
(stamp or print)