Chester Clinic

2011-2012 adult influenza vaccine administration record

Clark County Health Department 517 Court St., Rm 105 Neillsville, WI
54456
Phone: (715)743-5105 Toll Free 1-877-743-5105 Fax (715)743-5115 http://www.co.clark.wi.us 2013-2014 Child Influenza Vaccine Administration Record
(Flu Vaccine-Live/Intranasal)
The following questions will help us determine if there is any reason we should not give your child the Live
Attenuated Intranasal Influenza vaccination today. If you answer "yes" to any question, it does not necessarily
mean you should not be vaccinated. It just means additional questions must be asked. If a question is not clear,
please ask your healthcare provider to explain it. The Health Department will keep this record on file and record it in
the Wisconsin Immunization Registry (WIR).
My child will be in grade during the 2013-2014 School Year
Is your child sick today?
☐Yes ☐No
Does the person to be vaccinated have an allergy to eggs or to a component of the influenza
vaccine?
Has the person to be vaccinated ever had a serious reaction to intranasal influenza vaccine
(FluMist) in the past?
Does the person to be vaccinated have a long-term health problem with heart disease, lung
disease, asthma, kidney disease, neurologic or neuromuscular disease, liver disease,
metabolic disease (e.g., diabetes), or anemia or another blood disorder?
If the person to be vaccinated is a child age 2 through 4 years, in the past 12 months, has a
healthcare provider ever told you that he or she had wheezing or asthma?
Does the person to be vaccinated have cancer, leukemia, HIV/AIDS, or any other immune
system problem; or, in the past 3 months, have they taken medications that weaken the
immune system, such as cortisone, prednisone, other steroids, or anticancer drugs; or have
they had radiation treatments?
Is the person to be vaccinated receiving antiviral medications?
☐Yes ☐No

Is the child or teen to be vaccinated receiving aspirin therapy or aspirin-containing therapy?
☐Yes ☐No

Is the person to be vaccinated pregnant or could she become pregnant within the next
Has the person to be vaccinated ever had Guillain-Barré syndrome?
☐Yes ☐No

Does the person to be vaccinated live with or expect to have close contact with a person
whose immune system is severely compromised and who must be in protective isolation (e.g.,
an isolation room of a bone marrow transplant unit)?
Has the person to be vaccinated received any other vaccinations in the past 4 weeks?
☐Yes ☐No

I have read or have had explained to me the information about influenza and influenza vaccine. I have had a chance to ask questions that were answered to my satisfaction. I understand the benefits and risks of influenza vaccine and ask that the vaccine be given to me or the person named below whom I am authorized to make this request. I have received a copy of the Vaccine Information Statement dated 07/26/13. Information about the person to receive influenza vaccine. (Please Print) Name: Last First M.I. Birthdate Age Sex: Male or Female Address: Street City County State Zip Phone # By signing below, I authorize the Clark County Health Department to administer the influenza vaccine to the person
named above. Please return this form to your child's teacher.
Signature: X _ Date: _
Manufacturer: Manufacturer: Medimmune Signature of Vaccine Administrator: _Date Administered: _ Of fice Use Only ------------------------------------------------------------------------------------------------------------------------------------------------------------1. Is the person to be vaccinated sick today? There is no evidence that acute illness reduces vaccine efficacy or increases vaccine adverse events. People with an acute febrile illness usually should not be vaccinated until their symptoms have improved. Minor illnesses with or without fever do not contraindicate use of of the influenza vaccine. Do not withhold vaccination if a person is taking antibiotics. 2. Does the person to be vaccinated have an allergy to eggs or to a component of the influenza vaccine? A history of anaphylactic or non-anaphylactic reaction—such as hives, wheezing, or difficulty breathing, or circulatory collapse or shock (not fainting)—after eating eggs or receiving any component of the intranasal live attenuated influenza vaccine (LAIV, tradename FluMist) is usually a contraindication for further doses. People with egg allergy can usually be vaccinated with trivalent inactivated influenza vaccine (TIV); consult ACIP recommendations (see source 3). For a complete list of vaccine components (i.e., excipients and culture media) used in the production of the vaccine, check the package insert (at www. immunize.org/packageinserts) or go to www.cdc.gov/vaccines/pubs/pinkbook/downloads/appendices/b/excipient-table-2.pdf. 3. Has the person to be vaccinated ever had a serious reaction to intranasal influenza vaccine (FluMist) in the past? Patients reporting a serious reaction to a previous dose of LAIV should be asked to describe their symptoms. Immediate—presumably allergic—reactions are usually a contraindication to further vaccination with LAIV. 4. Does the person to be vaccinated have a long-term health problem with heart disease, lung disease, asthma, kidney disease, neurologic or neuromuscular disease, liver disease, metabolic disease (e.g., diabetes), or anemia or another blood disorder? People with any of these health conditions should not be given LAIV. Instead, they should be vaccinated with the inactivated injectable influenza vaccine. 5. If the person to be vaccinated is a child age 2 through 4 years, in the past 12 months, has a healthcare provider ever told you that he or she had wheezing or asthma? LAIV is not recommended for a child this age if their parent or guardian answers yes to this question or if the child has a history of asthma or recurrent wheezing. Instead, the child should be given the inactivated injectable influenza vaccine. 6. Does the person to be vaccinated have cancer, leukemia, HIV/AIDS, or any other immune system problem; or, in the past 3 months, have they taken medications that weaken the immune system, such as cortisone, prednisone, other steroids, or anticancer drugs; or have they had radiation treatments? People with weakened immune systems should not be given LAIV. Instead, they should be given the inactivated injectable influenza vaccine. 7. Is the person to be vaccinated receiving antiviral medications? Receipt of certain influenza antivirals (e.g., amantadine, rimantadine, zanamivir, oseltamivir) could reduce LAIV vaccine efficacy; therefore, providers may want to defer vaccination with LAIV in people who took these antivirals within the previous 48 hours and to advise avoiding use of these antivirals for 14 days after vaccination, if feasible. 8. Is the child or teen to be vaccinated receiving aspirin therapy or aspirin-containing therapy? Because of the theoretical risk of Reye's syndrome, children and teens on aspirin therapy should not be given LAIV. Instead they should be vaccinated with the inactivated injectable influenza vaccine. 9. Is the person to be vaccinated pregnant or could she become pregnant within the next month? Pregnant women or women planning to become pregnant within a month should not be given LAIV. All pregnant women should, however, be vaccinated with the inactivated injectable influenza vaccine. 10. Has the person to be vaccinated ever had Guillain-Barré syndrome? It is prudent to avoid vaccinating people who are not at high risk for severe influenza complications but who are known to have developed Guillain-Barré syndrome (GBS) within 6 weeks after receiving a previous influenza vaccination. As an alternative, physicians might consider using influenza antiviral chemoprophylaxis for these people. Although data are limited, the established benefits of influenza vaccination for the majority of people who have a history of GBS, and who are at high risk for severe complications from influenza, justify yearly vaccination. 11. Does the person to be vaccinated live with or expect to have close contact with a person whose immune system is severely compromised and who must be in a protective isolation (e.g., an isolation room of a bone marrow transplant unit)? Inactivated injectable influenza vaccine is preferred for people who anticipate close contact with a severely immunosuppressed person during periods in which the immunosuppressed person requires care in protective isolation (e.g., in a specialized patient-care area with a positive airflow relative to the corridor, high-efficiency particulate air filtration, and frequent air changes). Either the inactivated injectable influenza vaccine or LAIV may be used in people who have close contact with people having lesser degrees of immunosuppression. 12. Has the person to be vaccinated received any other vaccinations in the past 4 weeks? People who were given an injectable live virus vaccine (e.g., MMR, MMRV, varicella, zoster, yellow fever) in the past 4 weeks should wait 28 days before receiving LAIV. There is no reason to defer giving LAIV if people were vaccinated with an inactivated vaccine or if they have recently received blood or other antibody-containing blood products (e.g., IG).

Source: http://www.co.clark.wi.us/DocumentCenter/View/1001