School age flu vaccination consent form

School Age Immunisations Team

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Flu immunisation consent form 2020/21

Please complete one per child and return immediately to school in the original envelope.

Student details
Surname: First name:
Date of birth:______/_______/20______ NHS number (if known):
Home address:

 

 

Post code:

School:
Year group:
Class:
GP name and address:

 

Parent/guardian mobile:
Home telephone:
We collect information on ethnicity and gender to help us understand needs and to tailor our services. The information from this form also helps us to make sure our services are fair and promote equality.
Ethnic origin: Gender:
Health information
Has your child received a flu vaccination since September 2020? YES No
Is your child receiving salicylate therapy? i.e. prescribed aspirin YES No
Is your child on any other regular medication? YES No
Has your child had a severe (anaphylactic) allergic reaction to any previous vaccines? YES   No  
Does your child have an illness/receive treatment that severely affects their immune system? e.g. treatment for leukaemia YES   No  
Does your child have close contact with anyone having treatment that affects their immune system? e.g. they need to be kept in isolation? YES   No  
Does your child have a severe egg allergy (needing emergency treatment)? YES   No  
ASTHMA: Has your child been diagnosed with asthma? YES   No  
·         If Yes, and your child is currently taking inhaled steroids (i.e. uses a preventer or regular inhaler), please enter the medication name and daily dose in the box below (e.g. Budesonide 100 micrograms, four puffs per day)

·         If Yes, and your child has taken steroid tablets because of their asthma in the past two weeks, please give details below.

Please let the immunisation team know if your child has had to increase their asthma medication after you have returned this form. On the day of vaccination, let the immunisation team know if your child has been wheezy in the past 3 days.

*If you answered Yes to any of the above, please give details:

 

 

 

Please let the immunisation team know if your child has to increase their asthma medication after you have returned this form.

If you child has any other health needs please give details:

 

The nasal flu vaccine contains products derived from pigs (porcine gelatine). There is no suitable alternative flu vaccine available for otherwise healthy children. More information for parents is available from www.bit.ly/childrens-flu-vaccine.
Consent for immunisation (please tick YES or NO)
? YES I consent for my child to receive the flu immunisation and I have read and understood the information about the flu nasal spray.

 

Date   _____/_____/2020

? NO I do not consent to my child receiving the flu immunisation and I have read and understood the information about the flu nasal spray.
If ‘NO’ please give reason(s):Date   _____/_____/2020
Signature of parent/carer (with parental responsibility):
PLEASE PRINT NAME AND RELATIONSHIP TO CHILD:
Please note that information about your child’s immunisation will be shared with your GP, NHS and related organisations

We may need to contact you if we need further clarification. If you change your mind about consent please contact us on 01275 373104. Changes must be notified to us at least two working days before the school immunisation clinic date.

TO BE COMPLETED BY IMMUNISATION TEAM NURSE

Pre session eligibility assessment for live attenuated influenza vaccine LAIV
Child eligible for LAIV? YES No
If no, give details
Additional information:
Assessment completed by:       

Name:                                       Date:

 

Designation:                                   Signature:

Eligibility assessment on day of vaccination1
Has the parent/child reported the child being wheezy over the past three days? YES No
If the child has asthma, has the parent/child reported:

·         Use of oral steroids in the past 14 days?

·         An increase in inhaled steroids since consent form completed?

 

YES YES

 

No

No

Child eligible for LAIV? YES No
Vaccine details
Date:

 

 

Time:

 

Batch number:

 

 

Expiry date:
Administered by
Name:

 

 

Date:

 

 

Designation: Registered Nurse

 

 

Signature:

 

 

Invite to clinic YES No

1 Asthmatic children not eligible on the day of the session due to deterioration in their asthma control should be offered inactivated vaccine if their condition doesn’t improve within 72 hours to avoid a delay in vaccinating this ‘at risk’ group.

Privacy statement

This service is provided by Sirona care & health, as part of the Community Children’s Health Partnership (CCHP).

Keeping your personal information safe and secure is important to us – so we’ve updated our privacy notice to reflect the changes in data protection laws. For more detailed information on how we protect your information, you can read our Privacy Notice at www.sirona-cic.org.uk/policies.

If you have any queries about how your personal information is used or your rights, please contact our Data Protection Officer:

Email:

Telephone:

Post:

sirona.dataprotectionofficer@nhs.net

0300 124 5403

Data Protection Officer, Sirona care & health,  2nd Floor, Kingswood Civic Centre, High Street, Kingswood, Bristol, BS15 9TR