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If a second dose of influenza vaccine will be offered, additional information about influenza vaccination histories may need to be collected.While consent to be vaccinated is generally not regulated by federal law, federal law (as well as state law) may regulate the vaccinator’s use or disclosure of individually identifiable health information regarding the child.The first template consent form is designed for the injectable formulation of the vaccine, the second template consent form is designed for the intranasal formulation of the vaccine, and the third form is designed for both the injectable and the intranasal formulations.
Page last reviewed: November 15, 2016. Saving Lives, Protecting People Attached is a Hopefully, most providers will be supportive of the SLV clinics, but some may be concerned about vaccinations occurring outside of their offices, especially with regard to keeping their patient records up-to-date and having adequate information in case a patient seeks care for a possible vaccine-related adverse event. (Note: FERPA and HIPAA issues are discussed below under “State and local planners may consider distributing consent forms to parents in advance of influenza vaccine availability. Keeping providers informed about planned SLV clinics also will help them estimate how much influenza vaccine they will need to order for their own patients.The following are suggestions on the development of materials that should be delivered — via the child, mail, and/or email — to parents/guardians to inform them of the planned SLV clinic and solicit their permission to vaccinate their child. Partnerships with organizations such as the American Association of Pediatricians and the American Academy of Family Physicians may also add to the success of the SLV program and assist in gaining support from local physicians. Abbreviations: IIV=inactivated influenza vaccine; RIV=recombinant influenza vaccine; … Instead, requirements for informed consent are legislated or regulated by each state or jurisdiction, including the circumstances under which minors can consent to their own medical treatment. Linking to a non-federal website does not constitute an endorsement by CDC or any of its employees of the sponsors or the information and products presented on the website. %%EOF
Planners also should consider whether state/local law would require separate consents for administration of each of a two dose vaccine series.Important information about the use of the template consent form is provided above. As some influenza SLV programs do not offer second doses of influenza vaccine, these consent forms were developed for programs administering only one influenza vaccine to students. Influenza Consent I have read,or hadexplainedto me, the Vaccine Information Statement about influenza vaccination. Such forms are intended to be used in settings where children are vaccinated and the parent/legal guardian is not present. Please also refer to the section below on “Vaccine Information Statements (VISs) are information sheets produced by the CDC that explain to vaccine recipients, their parents, or their legal representatives both the benefits and risks of a vaccine. h�b``�b``�� $V�c@�@���� a�F�` �f�˶3�3��"=�E �aE�]�i�g��n��C���i�'�/�/]Q���|�� n83k��%L)p1�? For this reason, the success of SLV programs also will be enhanced by enlisting the support of local health care providers, especially pediatricians, family practitioners, obstetrician/gynecologists (since they often serve as primary care providers for adolescent girls), and community health clinics. Further, I hereby give my consent to the healthcare provider of Walgreens, Duane Reade or Take Care Health Services, as applicable (each an “applicable Provider”), to administer the vaccine(s) I have requested above.