This is because it is considered better at reducing the spread of flu to others and is easier to administer. This registration form provides the basic information needed to provide your site with influenza vaccine. h�b``����r����i�*`b�?Pn� �ĩP��� ����`��ؗ���=C�'�%{���@�g 7���!��9C�[�� @�mP����ۀ�=P�g$�w`y���@�G$���a���g1lڻ�ǔ��������+C��|����X^��� ��E�E�y�-�buFQ���z�•E���lg|#%�p�a��;V�����L30��"��iy 8ʸ��t������������~��x�:����/.w��l_��p���[W���5�k����bNn\|b2������^�>�v������VOߐ�2����+�:�\��/pʸyxi�#��N��'(�$ltra�Q0pp Z������1\�p�r1� Note: “ Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices — United States, 2020-2021 Influenza Season” has been published. 199 0 obj <> endobj COVID-19 info for Albertans & Health Professionals and about Family Support & Visitation. Policy Number Clinic/Office Site Where Vaccine Administered NYSIIS Permission ≥ 19 Years Old Doctor’s Address For Persons Under 19 Years Old, Mother’s Maiden Name Influenza/Pneumococcal Immunization Consent Form Influenza Consent I have read,or hadexplainedto me, the Vaccine Information Statement about influenza vaccination. PATIENT INFORMATION. A copy of this vaccination is being sent to your Atrium Health medical record as a convenience and benefit to you and your Atrium Health provider to enrich your record of immunizations. 0 h��=JCA������i\�n@Ac~DH�$�e Parents/guardians may seek the advice of others, including their child’s health care provider (Woodruff, 1996). Pharmasave West September 2020 AB/BC/MB/SK 1/2 2020/2021 INFLUENZA VACCINE CONSENT FORM . For the 2020-2021 Influenza Immunization Program all community providers are required to complete the Influenza Program Registration Form. Before receiving the vaccine, you provided verbal consent to receive the vaccine and were able to ask questions about the vaccine. Consent Details: Thank you from the Atrium Health Teammate Health for receiving your vaccination for the 2020 influenza season. These resources are designed to help prevent and manage the spread of Influenza like-illness (ILI) and seasonal Influenza. Are you allergic to the antibiotic’s neomycin, polymyxin or gentamycin? CDC recommends annual influenza vaccination for everyone 6 months and older with any licensed, age-appropriate flu vaccine (IIV, RIV4, or LAIV4) with no preference expressed for any … Providers are asked to complete this form in order for the Alberta Health Services (AHS) Zone Contact to obtain accurate accounting of the number of partners participating in the influenza immunization program. endstream endobj startxref In the U.S., children are vaccinated primarily in their pediatrician’s or family doctor’s office (Groom, 2007). Thank you for helping keep our teammates, patients and community safe. The purpose of this document is to provide best practice suggestions and considerations for the delivery of seasonal influenza vaccine by community pharmacists in fall 2020. Last Name First Name Middle Initial Date of Birth Age Street Address City State ZIP Code Phone Number Place a checkmark about the person getting vaccinated: Race: American Indian/Alsk. The nasal flu vaccine contains a highly processed form of gelatine derived from pigs (porcine gelatine). Consent Form 2020 Quadrivalent Influenza Vaccine Medical History Please answer the medical history questions below. © Alberta Health Services 2020 Terms of UsePrivacy Statement, Canadian Immunization Guide Chapter on Influenza and Statement on Seasonal Influenza Vaccine for 2020-2021, National Advisory Committee on Immunization Statement on Thimerosal, Thimerosal Information for Nurses and Other Vaccine Providers, Oculorespiratory Syndrome (ORS) Algorithm, Directions for use of Influenza Immunization Vaccine Record, Influenza Reporting Requirements and Coding Explanations Document, Community Provider Administered Vaccine Monthly Report, Influenza Immunization for Pregnant Women, Breastfeeding Women and Families with Newborns, Influenza Immunization Aftercare and Client Immunization Record, Routine and Seasonal Immunization during COVID-19, Cover Your Cough poster – Emergency Departments, Cover Your Cough poster – Clinics and Offices, Guideline: Influenza Immunization for Adult and Pediatric Patients Undergoing Cancer Treatment, Influenza Outbreak in this Facility Poster (11 x 17), Influenza Outbreak in this Facility Poster (8.5x11), Influenza Outbreak Poster for Staff and Physicians (8.5x11), Q & A – Use of Antivirals in Acute Care and Continuing Care Settings, Practice Recommendations for Seasonal Influenza, Contact and Droplet Precautions Info Sheet, Guidelines for Outbreak Prevention, Control and Management in Acute Care and Facility Living Sites, Choosing Personal Protective Equipment (PPE) for Resident Interactions in Continuing Care, Seasonal Influenza in Continuing Care: IPC Practice Recommendations, Guidelines for Influenza Immunization in Adult and Pediatric Patients with Cancer, Guidelines for Outbreak Prevention, Management and Control in Emergency Shelters and Transitional Housing Sites, Guidelines for Outbreak Prevention, Control and Management in Supportive Living and Home Living Sites, Outbreak Guidelines: Acute Care & Facility Living Sites, Pneumococcal Polysaccharide Vaccine Biological Page, Alberta Health Influenza Immunization Policy (IIP), Influenza Immunization during Covid-19: Guidance for the 2020-21 Season, Influenza Immunization Health Professionals.