2010-2011 FLU Influenza Vaccination Authorization Record

Flu (Injectable) Vaccination Authorization Manufacturer: Record and FluFIT Consent Form Lot Number: Expiration Date: Facility Site: This form must be signed by the vaccine recipient on the date the vaccine is administered. Admin Site: RA LA I have read or had explained to me the "Influenza Vaccine Information Statement." I have had an opportunity to ask questions which were answered to my satisfaction. I understand the benefits and risks of influenza vaccine and request that it be given to me or to the person for whom I am authorized to make this request. If I am between the ages of 50 and 75 and being offered a FIT kit for colorectal cancer screening today (if eligible), it has been explained to me.

Clini FIT Eligible FIT Given c Age 50-75, To Patient Staff Patient Name Primary Care no FIT this year, OR no colonoscopy in Initi Provider 10 yrs al □ Yes □ No □ Yes □ No

□ Declined

Please complete the following questions:

1. Is the person to be vaccinated sick today? YES or NO 2. Does the person to be vaccinated have an allergy to eggs or to a component of the vaccine? YES or NO 3. Has the person to be vaccinated ever had a serious reaction to influenza vaccine in the past? YES or NO 4. Has the person to be vaccinated ever had Guillain-Barre syndrome? YES or NO

Please complete the following questions if you are between the ages of 50 – 75 years old: 5. Are you between the ages of 50 – 75? YES or NO 6. Have you had a colonoscopy within the last 10 years? YES or NO a. If you have had a colonoscopy when/where was it performed? ______7. Have you done a home stool test for colorectal cancer within the last year? YES or NO 8. Do you have a personal history of Crohn’s disease or Ulcerative Colitis? YES or NO 9. Do you have a personal history of polyps or colorectal cancer? YES or NO 10.Do you have a personal history of polyps or cancer in a family member younger than age 60? YES or NO 11.Are you currently experiencing rectal bleeding, blood in your stool or other symptoms? YES or NO Comments:

[ ] Immunization given without incident [ ] VIS Refused [ ] VIS Given

Nurse Signature: ______Initials: _____ Date: ______

Patient Signature: ______Date: ______