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2009 H1N1 FLU VACCINE ADMINISTRATION RECORD
The confidentiality of shared information is protected under state and/or federal law. Health Department records are subject to Wisconsin State Statutes,
including but not limited to, Wisconsin State Stats 146.81-83, 51.30, 146.025. Since information in the Health Department records is protected under these
statutes, only information that is permissible to be released will be released.
Student’s Last Name
Male / Female
Parent/Legal Guardian’s Name Last
Month ____Date_____ Year ______
Parent/Guardian Daytime Phone Number
Does your child have:
1. Does your child have a serious allergy to eggs?
2. Does your child have any other serious allergies? Please list _________________________________________
3. Has your child ever had a serious reaction or allergic response to past flu vaccinations?
4. Has your child ever had Guillian Barre’syndrome (a type of temporary severe muscle weakness) within 6 weeks after
There are two types of 2009 H1N1 influenza vaccine (Injectable or Nasal). Your answers to the following questions
will help us know which of the two kinds of vaccine your child can get.
5. Has your child gotten vaccinated with any vaccine (not just flu) within the past 30 days?
Vaccine: ___________________________________ Date given: month _____day _____year _______
6. Does your child have any of the following: asthma, diabetes (or other type of metabolic disease), or disease of the
lungs, heart, kidneys, liver, nerves, or blood?
7. Is your child on long-term aspirin or aspirin-containing therapy (for example, does your child take aspirin every day)?
8. Does your child have a weak immune system (for example, from HIV, cancer, or medications such as steroids)
10. Does your child have close contact with a person who needs care in a protected environment (for example, someone
who has recently had a bone marrow transplant)?
CONSENT FOR CHILD’S VACCINATION:
The above noted information is accurate to the best of my knowledge. 2009 – 2010 H1N1 Influenza vaccine
information statement(s) have been provided to explain the benefits and risks of the vaccine. I have read and
fully understand the side effects of the H1N1 influenza vaccine and am the person authorized to make the request
(Parent, Guardian or Healthcare Power of Attorney) for the above named individual to receive the vaccine.
____________________________________________________________ Date ___________________
Office Use Only
Vaccine Manufacturer ____________________________________
Site of injection: R / L deltoid
Signature of Vaccine Administrator________________________________________ DATE:
G:\swine flu 2009\2009 School H1N1 FLU VACCINE ADMINISTRATION RECORD.docx
Thrombosis Research (2005) 116, 465 — 470Effect of increasing doses of aspirin on plateletfunction as measured by PFA-100 in patients withdiabetesAdnan Abacia,T, Yucel Yilmazb, Mustafa Caliskanb, Fahri Bayramc,Mustafa Cetind, Ali Unald, Servet CetinbaDepartment of Cardiology, Gazi University School of Medicine, Ankara 06550, TurkeybDepartment of Cardiology, Erciyes University School of Me
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